| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
785 |
239 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
787 |
215 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,496 |
1,477 |
$40K |
| D1110 |
Prophylaxis - adult |
635 |
625 |
$31K |
| D2394 |
|
229 |
58 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
274 |
109 |
$26K |
| D0274 |
Bitewings - four radiographic images |
752 |
743 |
$24K |
| D0350 |
|
1,337 |
1,322 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,379 |
1,357 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,461 |
1,442 |
$17K |
| D1120 |
Prophylaxis - child |
512 |
506 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,465 |
1,426 |
$16K |
| D0460 |
|
867 |
856 |
$10K |
| D0272 |
Bitewings - two radiographic images |
303 |
301 |
$7K |
| D1351 |
Sealant - per tooth |
273 |
53 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$649.95 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
23 |
23 |
$593.38 |
| D1330 |
|
200 |
200 |
$257.25 |
| D0603 |
|
1,844 |
1,801 |
$0.00 |