| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
157 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
935 |
909 |
$26K |
| D1110 |
Prophylaxis - adult |
465 |
449 |
$24K |
| D0274 |
Bitewings - four radiographic images |
655 |
633 |
$20K |
| D1120 |
Prophylaxis - child |
432 |
417 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,029 |
999 |
$14K |
| D1351 |
Sealant - per tooth |
538 |
134 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,056 |
1,022 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,064 |
994 |
$11K |
| D0272 |
Bitewings - two radiographic images |
215 |
212 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$123.58 |
| D0603 |
|
404 |
398 |
$9.01 |
| D0602 |
|
436 |
427 |
$0.00 |
| D0601 |
|
128 |
122 |
$0.00 |