| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,272 |
526 |
$131K |
| D1110 |
Prophylaxis - adult |
1,039 |
1,037 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
684 |
677 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
363 |
187 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
701 |
695 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
171 |
101 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
641 |
640 |
$17K |
| D1351 |
Sealant - per tooth |
353 |
41 |
$11K |
| D0274 |
Bitewings - four radiographic images |
214 |
214 |
$7K |
| D4341 |
|
35 |
12 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
142 |
$6K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
349 |
345 |
$5K |
| D1206 |
Topical application of fluoride varnish |
211 |
211 |
$5K |
| D2950 |
|
18 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
151 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$600.00 |
| D1330 |
|
69 |
67 |
$36.00 |