| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,803 |
1,436 |
$167K |
| D1110 |
Prophylaxis - adult |
2,774 |
2,774 |
$137K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
863 |
645 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,347 |
2,347 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
1,354 |
1,348 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
955 |
955 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,392 |
1,392 |
$38K |
| D1206 |
Topical application of fluoride varnish |
2,072 |
2,072 |
$34K |
| D0160 |
|
330 |
330 |
$29K |
| D1120 |
Prophylaxis - child |
594 |
594 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
169 |
156 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,401 |
1,378 |
$17K |
| D0272 |
Bitewings - two radiographic images |
743 |
743 |
$14K |
| D0330 |
Panoramic radiographic image |
233 |
233 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
169 |
$2K |
| D2331 |
|
13 |
12 |
$1K |