| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
630 |
327 |
$15K |
| D1110 |
Prophylaxis - adult |
1,100 |
1,032 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,356 |
1,279 |
$9K |
| D1120 |
Prophylaxis - child |
660 |
630 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
410 |
386 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
978 |
948 |
$5K |
| D0274 |
Bitewings - four radiographic images |
621 |
599 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
210 |
197 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,045 |
977 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
74 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
650 |
505 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
40 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$378.84 |
| D1206 |
Topical application of fluoride varnish |
142 |
133 |
$329.87 |
| D0272 |
Bitewings - two radiographic images |
64 |
59 |
$310.92 |
| D0602 |
|
62 |
58 |
$0.00 |
| D0601 |
|
14 |
14 |
$0.00 |