| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
803 |
225 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
1,237 |
1,067 |
$26K |
| D1120 |
Prophylaxis - child |
893 |
775 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,193 |
1,114 |
$24K |
| D1110 |
Prophylaxis - adult |
407 |
390 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
179 |
59 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,402 |
1,228 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
970 |
957 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,537 |
1,222 |
$13K |
| D1351 |
Sealant - per tooth |
728 |
97 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$3K |
| D1206 |
Topical application of fluoride varnish |
423 |
262 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$859.64 |
| D0272 |
Bitewings - two radiographic images |
94 |
49 |
$841.68 |
| D0140 |
Limited oral evaluation - problem focused |
54 |
52 |
$300.48 |
| D0330 |
Panoramic radiographic image |
59 |
41 |
$176.86 |
| D0603 |
|
905 |
844 |
$0.00 |
| D0601 |
|
479 |
467 |
$0.00 |