| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
58 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
219 |
219 |
$6K |
| D1120 |
Prophylaxis - child |
185 |
185 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
416 |
226 |
$5K |
| D1110 |
Prophylaxis - adult |
86 |
85 |
$4K |
| D0274 |
Bitewings - four radiographic images |
149 |
147 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
283 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
32 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
235 |
235 |
$3K |
| D1351 |
Sealant - per tooth |
114 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
32 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
44 |
$1K |
| D0603 |
|
350 |
347 |
$0.00 |