| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
753 |
350 |
$74K |
| D1110 |
Prophylaxis - adult |
868 |
845 |
$44K |
| D1351 |
Sealant - per tooth |
1,662 |
388 |
$43K |
| D1120 |
Prophylaxis - child |
1,148 |
1,126 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,220 |
1,181 |
$39K |
| D0145 |
Oral evaluation for a patient under three years of age |
285 |
283 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,519 |
1,927 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,316 |
1,278 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,890 |
1,850 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
332 |
186 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,177 |
2,074 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
703 |
689 |
$24K |
| D0272 |
Bitewings - two radiographic images |
659 |
649 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
82 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$225.36 |
| D1330 |
|
36 |
36 |
$12.50 |
| D0603 |
|
2,331 |
2,295 |
$0.00 |