| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,001 |
517 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
532 |
532 |
$35K |
| D1110 |
Prophylaxis - adult |
361 |
358 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
400 |
398 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
274 |
179 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
338 |
177 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
358 |
358 |
$17K |
| D1120 |
Prophylaxis - child |
506 |
501 |
$16K |
| D1351 |
Sealant - per tooth |
226 |
64 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
409 |
408 |
$4K |
| D2335 |
|
31 |
12 |
$4K |
| D2330 |
|
42 |
29 |
$3K |
| D0272 |
Bitewings - two radiographic images |
252 |
252 |
$3K |
| D9430 |
|
84 |
83 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
129 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
47 |
$486.00 |
| D1330 |
|
142 |
142 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |