| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,375 |
1,123 |
$112K |
| D1120 |
Prophylaxis - child |
1,970 |
1,970 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,359 |
1,091 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,368 |
2,367 |
$67K |
| D1206 |
Topical application of fluoride varnish |
1,381 |
1,381 |
$37K |
| D4341 |
|
160 |
107 |
$32K |
| D1110 |
Prophylaxis - adult |
563 |
563 |
$27K |
| D1351 |
Sealant - per tooth |
292 |
221 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,275 |
1,274 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
806 |
806 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,513 |
2,485 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
547 |
544 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
151 |
128 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
432 |
432 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
588 |
576 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,140 |
2,137 |
$10K |
| D2330 |
|
46 |
38 |
$4K |
| D0330 |
Panoramic radiographic image |
125 |
125 |
$3K |
| D0270 |
|
381 |
379 |
$2K |
| D0272 |
Bitewings - two radiographic images |
142 |
142 |
$2K |
| D4910 |
|
14 |
14 |
$938.00 |