| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,705 |
1,295 |
$333K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
700 |
391 |
$105K |
| D1120 |
Prophylaxis - child |
2,299 |
2,299 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
2,799 |
2,799 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
796 |
416 |
$72K |
| D1110 |
Prophylaxis - adult |
1,355 |
1,354 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,662 |
2,662 |
$63K |
| D0274 |
Bitewings - four radiographic images |
915 |
915 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
478 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,194 |
1,161 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
428 |
422 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
198 |
198 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,221 |
651 |
$10K |
| D7111 |
|
83 |
54 |
$6K |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$2K |
| D0240 |
|
113 |
57 |
$2K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$450.00 |