| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
75 |
$21K |
| D1351 |
Sealant - per tooth |
546 |
76 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
503 |
487 |
$14K |
| D1110 |
Prophylaxis - adult |
208 |
204 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
706 |
685 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
57 |
$9K |
| D1120 |
Prophylaxis - child |
262 |
256 |
$9K |
| D0274 |
Bitewings - four radiographic images |
185 |
175 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
517 |
367 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
134 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
393 |
372 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
18 |
18 |
$3K |
| D0272 |
Bitewings - two radiographic images |
72 |
71 |
$2K |
| D0603 |
|
385 |
373 |
$0.00 |
| D0602 |
|
205 |
200 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |