| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
888 |
264 |
$109K |
| D2332 |
|
494 |
172 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
475 |
183 |
$47K |
| D2335 |
|
185 |
76 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
293 |
125 |
$28K |
| D1110 |
Prophylaxis - adult |
262 |
260 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
390 |
388 |
$13K |
| D2394 |
|
77 |
41 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
309 |
309 |
$9K |
| D0274 |
Bitewings - four radiographic images |
199 |
198 |
$8K |
| D1120 |
Prophylaxis - child |
206 |
206 |
$8K |
| D0240 |
|
368 |
128 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
108 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$5K |
| D1320 |
|
164 |
155 |
$5K |
| D1351 |
Sealant - per tooth |
80 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
109 |
109 |
$2K |