| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,199 |
613 |
$119K |
| D1110 |
Prophylaxis - adult |
2,198 |
2,189 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,008 |
484 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,991 |
2,971 |
$66K |
| D0140 |
Limited oral evaluation - problem focused |
1,535 |
1,473 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,469 |
1,461 |
$36K |
| D1120 |
Prophylaxis - child |
781 |
779 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,395 |
2,338 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
916 |
914 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
369 |
364 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,282 |
1,976 |
$14K |
| D4355 |
|
122 |
120 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
192 |
$6K |
| D1351 |
Sealant - per tooth |
69 |
18 |
$2K |
| D0272 |
Bitewings - two radiographic images |
26 |
25 |
$596.65 |