| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,966 |
991 |
$260K |
| D1110 |
Prophylaxis - adult |
2,816 |
2,777 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
2,977 |
2,922 |
$67K |
| D0274 |
Bitewings - four radiographic images |
2,094 |
2,069 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
2,887 |
2,822 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,113 |
2,082 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
69 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
172 |
110 |
$17K |
| D1206 |
Topical application of fluoride varnish |
698 |
687 |
$13K |
| D4342 |
|
131 |
53 |
$12K |
| D0180 |
|
276 |
274 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
354 |
348 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
246 |
$9K |
| D0330 |
Panoramic radiographic image |
115 |
115 |
$6K |
| D4910 |
|
45 |
40 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
52 |
$2K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$2K |
| D0350 |
|
25 |
25 |
$767.35 |