| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
391 |
218 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
333 |
328 |
$5K |
| D1110 |
Prophylaxis - adult |
175 |
170 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
79 |
$4K |
| D1120 |
Prophylaxis - child |
191 |
189 |
$4K |
| D0274 |
Bitewings - four radiographic images |
214 |
210 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
380 |
377 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
315 |
272 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
297 |
288 |
$2K |
| D1351 |
Sealant - per tooth |
134 |
41 |
$2K |
| D0272 |
Bitewings - two radiographic images |
125 |
125 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$781.44 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
36 |
$529.80 |
| D0330 |
Panoramic radiographic image |
18 |
17 |
$134.52 |
| D0603 |
|
425 |
422 |
$0.00 |