| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
64 |
$23K |
| D1120 |
Prophylaxis - child |
219 |
213 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
28 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
234 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
142 |
$6K |
| D1206 |
Topical application of fluoride varnish |
174 |
173 |
$5K |
| D1110 |
Prophylaxis - adult |
111 |
107 |
$4K |
| D0274 |
Bitewings - four radiographic images |
192 |
186 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
271 |
$4K |
| D0272 |
Bitewings - two radiographic images |
136 |
133 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
250 |
212 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
95 |
$2K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$793.73 |