| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
71 |
$20K |
| D1351 |
Sealant - per tooth |
701 |
129 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
619 |
614 |
$17K |
| D1110 |
Prophylaxis - adult |
313 |
307 |
$16K |
| D0274 |
Bitewings - four radiographic images |
563 |
552 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,009 |
992 |
$14K |
| D1120 |
Prophylaxis - child |
353 |
351 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,141 |
352 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
566 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
32 |
31 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
26 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
90 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$533.79 |
| D0601 |
|
220 |
218 |
$0.01 |
| D0603 |
|
326 |
324 |
$0.00 |
| D0602 |
|
150 |
145 |
$0.00 |