| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,534 |
888 |
$182K |
| D1120 |
Prophylaxis - child |
1,925 |
1,924 |
$72K |
| D1206 |
Topical application of fluoride varnish |
2,403 |
2,402 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,078 |
2,075 |
$51K |
| D1110 |
Prophylaxis - adult |
507 |
506 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,407 |
1,374 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,785 |
999 |
$15K |
| D0274 |
Bitewings - four radiographic images |
357 |
357 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
25 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
37 |
$5K |
| D0272 |
Bitewings - two radiographic images |
89 |
89 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$933.00 |