| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
26 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
234 |
225 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
384 |
371 |
$5K |
| D1110 |
Prophylaxis - adult |
97 |
92 |
$5K |
| D0274 |
Bitewings - four radiographic images |
126 |
120 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
313 |
298 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
329 |
277 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
42 |
41 |
$1K |
| D1351 |
Sealant - per tooth |
75 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$459.16 |
| D0603 |
|
44 |
38 |
$0.00 |
| D0601 |
|
30 |
29 |
$0.00 |
| D0602 |
|
20 |
19 |
$0.00 |