| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,014 |
624 |
$121K |
| D1110 |
Prophylaxis - adult |
1,535 |
1,534 |
$78K |
| D2750 |
|
86 |
61 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,730 |
1,729 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
1,451 |
1,430 |
$22K |
| D1120 |
Prophylaxis - child |
537 |
535 |
$20K |
| D1206 |
Topical application of fluoride varnish |
796 |
794 |
$18K |
| D2950 |
|
79 |
59 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
75 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
318 |
317 |
$13K |
| D0274 |
Bitewings - four radiographic images |
384 |
384 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,489 |
1,172 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
291 |
279 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$300.00 |