| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
412 |
165 |
$37K |
| D1120 |
Prophylaxis - child |
451 |
437 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
563 |
544 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
109 |
104 |
$14K |
| D1351 |
Sealant - per tooth |
397 |
75 |
$10K |
| D1110 |
Prophylaxis - adult |
187 |
179 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
646 |
625 |
$9K |
| D0274 |
Bitewings - four radiographic images |
215 |
207 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
517 |
502 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
580 |
460 |
$6K |
| D0272 |
Bitewings - two radiographic images |
336 |
324 |
$5K |
| D0330 |
Panoramic radiographic image |
103 |
98 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
19 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
53 |
$2K |
| D0603 |
|
794 |
775 |
$0.00 |