| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,060 |
675 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,184 |
2,183 |
$61K |
| D1110 |
Prophylaxis - adult |
1,098 |
1,097 |
$40K |
| D1120 |
Prophylaxis - child |
1,116 |
1,116 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,238 |
1,238 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,399 |
1,393 |
$19K |
| D0330 |
Panoramic radiographic image |
413 |
413 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
218 |
128 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,272 |
2,236 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,931 |
1,895 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
42 |
$4K |
| D1351 |
Sealant - per tooth |
134 |
25 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
224 |
224 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
89 |
$2K |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$598.00 |
| D1330 |
|
775 |
695 |
$0.00 |