| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
528 |
233 |
$36K |
| D1120 |
Prophylaxis - child |
525 |
524 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
806 |
804 |
$21K |
| D1110 |
Prophylaxis - adult |
527 |
525 |
$21K |
| D1206 |
Topical application of fluoride varnish |
553 |
552 |
$17K |
| D0274 |
Bitewings - four radiographic images |
420 |
420 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,076 |
1,042 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$4K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
910 |
892 |
$2K |
| D0272 |
Bitewings - two radiographic images |
173 |
173 |
$2K |
| D1351 |
Sealant - per tooth |
60 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$540.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$325.00 |
| D0602 |
|
13 |
13 |
$130.00 |
| D1330 |
|
214 |
208 |
$0.00 |