| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
141 |
$22K |
| D1206 |
Topical application of fluoride varnish |
666 |
650 |
$16K |
| D1120 |
Prophylaxis - child |
444 |
440 |
$14K |
| D0330 |
Panoramic radiographic image |
167 |
166 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
393 |
377 |
$10K |
| D1110 |
Prophylaxis - adult |
179 |
167 |
$10K |
| D0272 |
Bitewings - two radiographic images |
288 |
288 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
129 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
175 |
$6K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
235 |
$3K |
| D1351 |
Sealant - per tooth |
87 |
31 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
28 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
40 |
$1K |
| D9996 |
|
15 |
15 |
$615.00 |
| D0240 |
|
12 |
12 |
$125.00 |