| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,751 |
666 |
$219K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
626 |
364 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
766 |
409 |
$72K |
| D1120 |
Prophylaxis - child |
1,213 |
1,212 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,516 |
1,514 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,373 |
1,372 |
$34K |
| D1110 |
Prophylaxis - adult |
413 |
412 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
243 |
242 |
$17K |
| D2394 |
|
87 |
64 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
903 |
892 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
308 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,366 |
724 |
$10K |
| D0274 |
Bitewings - four radiographic images |
329 |
329 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
277 |
271 |
$8K |
| D0272 |
Bitewings - two radiographic images |
276 |
276 |
$7K |
| D3240 |
|
32 |
25 |
$4K |
| D1351 |
Sealant - per tooth |
134 |
48 |
$4K |
| D4355 |
|
30 |
30 |
$2K |