| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,152 |
692 |
$79K |
| D1110 |
Prophylaxis - adult |
1,573 |
1,566 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,028 |
2,023 |
$55K |
| D1120 |
Prophylaxis - child |
761 |
761 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,001 |
998 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
659 |
656 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,826 |
1,788 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
256 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
571 |
560 |
$20K |
| D1206 |
Topical application of fluoride varnish |
974 |
974 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
269 |
269 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,387 |
1,274 |
$12K |
| D4341 |
|
95 |
37 |
$8K |
| D4910 |
|
13 |
13 |
$840.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$532.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$280.00 |