| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
484 |
263 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
960 |
949 |
$19K |
| D1110 |
Prophylaxis - adult |
492 |
482 |
$14K |
| D1120 |
Prophylaxis - child |
727 |
702 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,012 |
990 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,089 |
1,048 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
254 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
854 |
838 |
$6K |
| D0330 |
Panoramic radiographic image |
162 |
145 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
41 |
$3K |
| D1999 |
|
181 |
175 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
778 |
731 |
$2K |
| D1351 |
Sealant - per tooth |
62 |
16 |
$659.40 |
| D1206 |
Topical application of fluoride varnish |
35 |
30 |
$311.82 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$79.02 |