| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
486 |
225 |
$64K |
| D2750 |
|
125 |
88 |
$60K |
| D1110 |
Prophylaxis - adult |
923 |
900 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,171 |
2,119 |
$54K |
| D1120 |
Prophylaxis - child |
1,129 |
1,105 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,368 |
1,333 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
619 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
251 |
100 |
$27K |
| D1351 |
Sealant - per tooth |
474 |
69 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
265 |
254 |
$14K |
| D2950 |
|
124 |
90 |
$11K |
| D0274 |
Bitewings - four radiographic images |
451 |
440 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
215 |
196 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$9K |
| D0272 |
Bitewings - two radiographic images |
562 |
552 |
$9K |
| D1330 |
|
825 |
801 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
398 |
355 |
$4K |
| D4341 |
|
43 |
12 |
$4K |
| D4355 |
|
22 |
22 |
$2K |
| D3120 |
|
35 |
17 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$989.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$268.96 |