| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
963 |
512 |
$140K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
755 |
444 |
$88K |
| D1120 |
Prophylaxis - child |
1,823 |
1,823 |
$71K |
| D1110 |
Prophylaxis - adult |
1,254 |
1,252 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,397 |
2,395 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
2,308 |
2,272 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,231 |
2,042 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
475 |
472 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
714 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,132 |
1,132 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
258 |
138 |
$22K |
| D0274 |
Bitewings - four radiographic images |
592 |
590 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,009 |
1,008 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
412 |
409 |
$17K |
| D0272 |
Bitewings - two radiographic images |
545 |
545 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
187 |
82 |
$13K |
| D1351 |
Sealant - per tooth |
276 |
76 |
$8K |
| D2394 |
|
33 |
27 |
$5K |
| D4355 |
|
37 |
37 |
$3K |
| D7111 |
|
17 |
13 |
$1K |