| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
705 |
415 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
719 |
329 |
$69K |
| D1120 |
Prophylaxis - child |
1,719 |
1,715 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,103 |
2,098 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,848 |
1,846 |
$50K |
| D1110 |
Prophylaxis - adult |
613 |
613 |
$32K |
| D1351 |
Sealant - per tooth |
856 |
148 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
555 |
555 |
$25K |
| D0272 |
Bitewings - two radiographic images |
840 |
839 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
845 |
826 |
$14K |
| D0330 |
Panoramic radiographic image |
195 |
195 |
$13K |
| D7111 |
|
89 |
65 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
119 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
366 |
237 |
$3K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$972.00 |