| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
370 |
138 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
265 |
100 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
478 |
$21K |
| D1120 |
Prophylaxis - child |
475 |
475 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,547 |
389 |
$14K |
| D1206 |
Topical application of fluoride varnish |
543 |
543 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
147 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
449 |
446 |
$8K |
| D1351 |
Sealant - per tooth |
233 |
72 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
143 |
$6K |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
61 |
61 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$250.00 |