| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
201 |
$42K |
| D0145 |
Oral evaluation for a patient under three years of age |
136 |
135 |
$19K |
| D1120 |
Prophylaxis - child |
445 |
440 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
547 |
538 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,603 |
740 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
775 |
766 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
867 |
826 |
$8K |
| D0274 |
Bitewings - four radiographic images |
250 |
245 |
$7K |
| D1351 |
Sealant - per tooth |
210 |
45 |
$6K |
| D1110 |
Prophylaxis - adult |
96 |
95 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
26 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
72 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$371.49 |
| D0140 |
Limited oral evaluation - problem focused |
45 |
44 |
$338.04 |
| D1330 |
|
373 |
369 |
$61.50 |
| D0602 |
|
1,282 |
1,269 |
$9.07 |