| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
583 |
202 |
$54K |
| D1120 |
Prophylaxis - child |
532 |
507 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
476 |
454 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
887 |
848 |
$12K |
| D0272 |
Bitewings - two radiographic images |
510 |
485 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
971 |
922 |
$8K |
| D1351 |
Sealant - per tooth |
336 |
72 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
910 |
869 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
40 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
170 |
$6K |
| D0330 |
Panoramic radiographic image |
110 |
108 |
$4K |
| D1110 |
Prophylaxis - adult |
39 |
37 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
37 |
$1K |
| D0603 |
|
972 |
933 |
$0.00 |
| D0601 |
|
19 |
19 |
$0.00 |