| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,083 |
512 |
$115K |
| D1110 |
Prophylaxis - adult |
1,212 |
1,194 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,661 |
1,626 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,936 |
1,898 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,190 |
1,170 |
$18K |
| D0274 |
Bitewings - four radiographic images |
544 |
538 |
$17K |
| D1120 |
Prophylaxis - child |
520 |
512 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,094 |
1,060 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
92 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
201 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
24 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$944.75 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$425.70 |