| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,422 |
687 |
$174K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,222 |
635 |
$132K |
| D1110 |
Prophylaxis - adult |
2,115 |
2,096 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,528 |
2,516 |
$59K |
| D1120 |
Prophylaxis - child |
1,271 |
1,262 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,488 |
1,463 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
3,656 |
3,575 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,309 |
1,298 |
$30K |
| D2394 |
|
196 |
128 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,222 |
1,216 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,387 |
2,766 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
869 |
845 |
$23K |
| D0272 |
Bitewings - two radiographic images |
625 |
618 |
$14K |
| D2160 |
|
206 |
109 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
236 |
236 |
$12K |
| D2161 |
|
76 |
37 |
$5K |
| D1351 |
Sealant - per tooth |
119 |
30 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
36 |
24 |
$2K |