| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
93 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
575 |
315 |
$13K |
| D0274 |
Bitewings - four radiographic images |
392 |
391 |
$12K |
| D1110 |
Prophylaxis - adult |
262 |
262 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
316 |
316 |
$10K |
| D0330 |
Panoramic radiographic image |
172 |
172 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
134 |
94 |
$8K |
| D1206 |
Topical application of fluoride varnish |
343 |
341 |
$8K |
| D1120 |
Prophylaxis - child |
153 |
153 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
341 |
339 |
$5K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
14 |
$923.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$615.00 |