| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
678 |
314 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
577 |
295 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
834 |
834 |
$47K |
| D1110 |
Prophylaxis - adult |
549 |
549 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
119 |
79 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
769 |
769 |
$19K |
| D0274 |
Bitewings - four radiographic images |
557 |
557 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,060 |
1,051 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
909 |
908 |
$11K |
| D2750 |
|
18 |
12 |
$9K |
| D1120 |
Prophylaxis - child |
145 |
145 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
99 |
$5K |
| D2950 |
|
36 |
27 |
$3K |
| D1351 |
Sealant - per tooth |
64 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
52 |
$2K |
| D1330 |
|
73 |
73 |
$525.60 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$443.07 |