| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
816 |
473 |
$87K |
| D1120 |
Prophylaxis - child |
2,100 |
2,098 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,434 |
2,432 |
$56K |
| D1206 |
Topical application of fluoride varnish |
2,324 |
2,319 |
$46K |
| D1110 |
Prophylaxis - adult |
701 |
701 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,633 |
1,616 |
$23K |
| D0274 |
Bitewings - four radiographic images |
637 |
637 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,023 |
1,243 |
$16K |
| D1351 |
Sealant - per tooth |
497 |
86 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
338 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
78 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
25 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
167 |
167 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$390.49 |