| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
979 |
612 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
2,955 |
2,822 |
$81K |
| D1120 |
Prophylaxis - child |
1,312 |
1,253 |
$53K |
| D1110 |
Prophylaxis - adult |
970 |
932 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,388 |
1,326 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,533 |
1,468 |
$28K |
| D1351 |
Sealant - per tooth |
314 |
159 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,869 |
2,676 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,991 |
2,843 |
$18K |
| D4342 |
|
71 |
28 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
312 |
287 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
279 |
$6K |
| D4341 |
|
25 |
12 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$478.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$253.80 |