| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,755 |
809 |
$229K |
| D1110 |
Prophylaxis - adult |
3,096 |
3,070 |
$149K |
| D0274 |
Bitewings - four radiographic images |
2,962 |
2,936 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
714 |
376 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,744 |
1,726 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,660 |
2,642 |
$66K |
| D0220 |
Intraoral - periapical first radiographic image |
3,936 |
3,891 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,586 |
3,553 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
1,334 |
1,320 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,117 |
1,105 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
26 |
$7K |
| D0350 |
|
128 |
126 |
$4K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
20 |
20 |
$3K |
| D8660 |
|
17 |
17 |
$2K |
| D0340 |
|
27 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$411.60 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$251.92 |