| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
601 |
250 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,189 |
1,138 |
$32K |
| D1120 |
Prophylaxis - child |
849 |
810 |
$28K |
| D1351 |
Sealant - per tooth |
790 |
171 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,902 |
923 |
$20K |
| D1110 |
Prophylaxis - adult |
391 |
375 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,291 |
1,241 |
$18K |
| D0274 |
Bitewings - four radiographic images |
421 |
390 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,024 |
980 |
$12K |
| D0272 |
Bitewings - two radiographic images |
346 |
333 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
53 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
65 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
77 |
72 |
$980.49 |
| D0603 |
|
1,689 |
1,620 |
$0.00 |