| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,343 |
1,111 |
$145K |
| D1110 |
Prophylaxis - adult |
1,795 |
1,795 |
$97K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
600 |
530 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,017 |
2,017 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,765 |
1,765 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
387 |
323 |
$26K |
| D1120 |
Prophylaxis - child |
495 |
495 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
624 |
$18K |
| D2750 |
|
15 |
13 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
818 |
818 |
$11K |
| D2394 |
|
60 |
58 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
524 |
516 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
286 |
282 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
149 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$118.44 |