| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
648 |
506 |
$69K |
| D1120 |
Prophylaxis - child |
1,105 |
1,105 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,611 |
1,607 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
464 |
359 |
$36K |
| D1110 |
Prophylaxis - adult |
712 |
704 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
909 |
909 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,015 |
985 |
$13K |
| D1351 |
Sealant - per tooth |
337 |
176 |
$12K |
| D0274 |
Bitewings - four radiographic images |
379 |
374 |
$11K |
| D1206 |
Topical application of fluoride varnish |
330 |
330 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
832 |
758 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
119 |
$4K |
| D0272 |
Bitewings - two radiographic images |
167 |
167 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$891.62 |
| D0601 |
|
240 |
240 |
$0.00 |
| D0602 |
|
103 |
103 |
$0.00 |
| D0603 |
|
13 |
13 |
$0.00 |
| D1999 |
|
15 |
15 |
$0.00 |