| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,223 |
818 |
$248K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
736 |
356 |
$66K |
| D1110 |
Prophylaxis - adult |
960 |
932 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
626 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
762 |
742 |
$20K |
| D0274 |
Bitewings - four radiographic images |
852 |
822 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
107 |
71 |
$15K |
| D1206 |
Topical application of fluoride varnish |
583 |
569 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,472 |
1,396 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
183 |
174 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,198 |
1,134 |
$7K |
| D1120 |
Prophylaxis - child |
119 |
118 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
158 |
157 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$684.00 |
| D1330 |
|
48 |
48 |
$288.00 |