| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,374 |
818 |
$168K |
| D1110 |
Prophylaxis - adult |
2,619 |
2,610 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
3,777 |
3,767 |
$99K |
| D1352 |
|
1,078 |
134 |
$75K |
| D1120 |
Prophylaxis - child |
1,648 |
1,648 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,363 |
2,362 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
486 |
486 |
$35K |
| D0274 |
Bitewings - four radiographic images |
738 |
738 |
$24K |
| D2750 |
|
32 |
29 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
743 |
730 |
$12K |
| D0180 |
|
237 |
237 |
$10K |
| D0240 |
|
384 |
196 |
$8K |
| D2950 |
|
39 |
30 |
$7K |
| D0272 |
Bitewings - two radiographic images |
225 |
225 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
392 |
350 |
$4K |
| D4355 |
|
13 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$1K |