| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
259 |
97 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,210 |
740 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
432 |
411 |
$11K |
| D1120 |
Prophylaxis - child |
353 |
333 |
$11K |
| D1351 |
Sealant - per tooth |
426 |
74 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
766 |
727 |
$10K |
| D0274 |
Bitewings - four radiographic images |
444 |
405 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
920 |
852 |
$8K |
| D1110 |
Prophylaxis - adult |
128 |
125 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
125 |
$4K |
| D0330 |
Panoramic radiographic image |
43 |
40 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$1K |
| D0350 |
|
54 |
52 |
$672.70 |
| D0603 |
|
719 |
679 |
$0.00 |
| D0602 |
|
346 |
312 |
$0.00 |