| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
446 |
141 |
$38K |
| D1351 |
Sealant - per tooth |
1,378 |
225 |
$29K |
| D1120 |
Prophylaxis - child |
805 |
734 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
690 |
617 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,149 |
1,048 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
447 |
410 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,737 |
1,206 |
$13K |
| D0274 |
Bitewings - four radiographic images |
548 |
507 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,378 |
1,240 |
$11K |
| D1110 |
Prophylaxis - adult |
189 |
182 |
$9K |
| D0272 |
Bitewings - two radiographic images |
436 |
395 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
43 |
$7K |
| D0330 |
Panoramic radiographic image |
221 |
208 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
15 |
$1K |
| D0602 |
|
539 |
505 |
$0.00 |
| D0603 |
|
436 |
415 |
$0.00 |
| D0601 |
|
136 |
128 |
$0.00 |