| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,066 |
555 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
844 |
435 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
933 |
901 |
$15K |
| D1110 |
Prophylaxis - adult |
955 |
920 |
$15K |
| D1120 |
Prophylaxis - child |
745 |
717 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
741 |
713 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
492 |
478 |
$10K |
| D1206 |
Topical application of fluoride varnish |
353 |
344 |
$5K |
| D0274 |
Bitewings - four radiographic images |
262 |
255 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
64 |
$1K |
| D1351 |
Sealant - per tooth |
129 |
24 |
$720.00 |
| D2394 |
|
14 |
12 |
$530.50 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
54 |
$158.25 |