| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
325 |
107 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,105 |
613 |
$12K |
| D1120 |
Prophylaxis - child |
349 |
334 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
406 |
392 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
631 |
612 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
637 |
615 |
$8K |
| D1110 |
Prophylaxis - adult |
142 |
140 |
$7K |
| D0272 |
Bitewings - two radiographic images |
288 |
283 |
$6K |
| D0274 |
Bitewings - four radiographic images |
114 |
107 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
85 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
108 |
14 |
$2K |
| D0603 |
|
804 |
771 |
$0.00 |