| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
996 |
420 |
$55K |
| D1110 |
Prophylaxis - adult |
1,520 |
1,408 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,833 |
1,714 |
$31K |
| D0274 |
Bitewings - four radiographic images |
775 |
714 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,121 |
1,039 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
559 |
514 |
$15K |
| D0330 |
Panoramic radiographic image |
477 |
429 |
$14K |
| D1120 |
Prophylaxis - child |
613 |
571 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
570 |
424 |
$12K |
| D1351 |
Sealant - per tooth |
784 |
156 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
340 |
308 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
41 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
402 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$745.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
24 |
$484.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
15 |
$429.21 |
| D1999 |
|
52 |
49 |
$15.00 |