| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,228 |
704 |
$110K |
| D1110 |
Prophylaxis - adult |
1,204 |
1,204 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
766 |
765 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
842 |
842 |
$18K |
| D0274 |
Bitewings - four radiographic images |
636 |
636 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
595 |
595 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
161 |
105 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
962 |
953 |
$9K |
| D1351 |
Sealant - per tooth |
179 |
38 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
732 |
732 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
74 |
$4K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
329 |
329 |
$4K |
| D0330 |
Panoramic radiographic image |
98 |
98 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
210 |
$2K |
| D2331 |
|
22 |
13 |
$924.02 |