| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
73 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
207 |
179 |
$4K |
| D1120 |
Prophylaxis - child |
148 |
114 |
$3K |
| D0274 |
Bitewings - four radiographic images |
157 |
128 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
301 |
247 |
$3K |
| D1110 |
Prophylaxis - adult |
92 |
72 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
85 |
$2K |
| D0330 |
Panoramic radiographic image |
120 |
79 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
160 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
223 |
167 |
$2K |
| D0272 |
Bitewings - two radiographic images |
91 |
65 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
14 |
$994.49 |
| D1351 |
Sealant - per tooth |
64 |
12 |
$875.44 |
| D1330 |
|
437 |
320 |
$594.08 |
| D0350 |
|
90 |
14 |
$150.28 |
| D1999 |
|
355 |
235 |
$0.00 |
| D0603 |
|
370 |
299 |
$0.00 |
| D9215 |
|
108 |
83 |
$0.00 |