| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
99 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,667 |
506 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
94 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
422 |
414 |
$11K |
| D1120 |
Prophylaxis - child |
268 |
261 |
$9K |
| D1110 |
Prophylaxis - adult |
131 |
125 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
538 |
521 |
$6K |
| D1206 |
Topical application of fluoride varnish |
395 |
386 |
$6K |
| D0274 |
Bitewings - four radiographic images |
121 |
115 |
$4K |
| D1351 |
Sealant - per tooth |
138 |
41 |
$3K |
| D2330 |
|
17 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
29 |
$426.30 |
| D0603 |
|
497 |
486 |
$0.00 |