| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
606 |
324 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
1,594 |
1,574 |
$10K |
| D1110 |
Prophylaxis - adult |
790 |
784 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
2,655 |
2,537 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,850 |
1,828 |
$9K |
| D1120 |
Prophylaxis - child |
851 |
837 |
$8K |
| D0274 |
Bitewings - four radiographic images |
971 |
959 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,130 |
1,956 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
390 |
357 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
78 |
$3K |
| D0272 |
Bitewings - two radiographic images |
319 |
316 |
$995.12 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
28 |
$790.74 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$359.58 |
| D1351 |
Sealant - per tooth |
46 |
12 |
$306.48 |
| D1330 |
|
593 |
562 |
$0.00 |