| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
57 |
$8K |
| D1110 |
Prophylaxis - adult |
133 |
121 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
92 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
134 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
120 |
$5K |
| D1320 |
|
96 |
86 |
$2K |
| D0270 |
|
104 |
84 |
$2K |
| D1351 |
Sealant - per tooth |
60 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
108 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
31 |
$559.75 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$386.09 |