| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
760 |
410 |
$56K |
| D1110 |
Prophylaxis - adult |
980 |
955 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
406 |
214 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
940 |
915 |
$39K |
| D0330 |
Panoramic radiographic image |
860 |
837 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,055 |
1,033 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,134 |
1,109 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,364 |
1,301 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
82 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
235 |
232 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
181 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,070 |
1,039 |
$5K |
| D1351 |
Sealant - per tooth |
213 |
34 |
$5K |
| D4341 |
|
38 |
13 |
$2K |
| D1999 |
|
130 |
106 |
$1K |
| D0270 |
|
13 |
12 |
$52.08 |
| D1330 |
|
19 |
19 |
$0.00 |