| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
70 |
$15K |
| D1110 |
Prophylaxis - adult |
214 |
205 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,018 |
489 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
394 |
376 |
$10K |
| D0274 |
Bitewings - four radiographic images |
356 |
335 |
$10K |
| D1120 |
Prophylaxis - child |
312 |
301 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
252 |
242 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
535 |
512 |
$6K |
| D1206 |
Topical application of fluoride varnish |
433 |
421 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
67 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
27 |
$4K |
| D1351 |
Sealant - per tooth |
121 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
82 |
80 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
14 |
$204.33 |
| D0603 |
|
672 |
647 |
$0.00 |