| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
998 |
404 |
$81K |
| D1110 |
Prophylaxis - adult |
909 |
855 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,013 |
940 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,095 |
1,025 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
222 |
123 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,167 |
1,218 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,481 |
1,360 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
738 |
687 |
$18K |
| D0330 |
Panoramic radiographic image |
294 |
277 |
$18K |
| D1351 |
Sealant - per tooth |
523 |
70 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
238 |
118 |
$15K |
| D1206 |
Topical application of fluoride varnish |
570 |
541 |
$13K |
| D4346 |
|
56 |
54 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
190 |
183 |
$7K |
| D1320 |
|
105 |
101 |
$4K |
| D1120 |
Prophylaxis - child |
91 |
85 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
16 |
$100.37 |
| D1330 |
|
174 |
167 |
$0.00 |
| D1310 |
|
167 |
160 |
$0.00 |