| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,343 |
531 |
$133K |
| D1351 |
Sealant - per tooth |
2,568 |
578 |
$68K |
| D0145 |
Oral evaluation for a patient under three years of age |
305 |
304 |
$43K |
| D1120 |
Prophylaxis - child |
1,154 |
1,146 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,444 |
1,888 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,185 |
1,173 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,817 |
1,797 |
$26K |
| D0274 |
Bitewings - four radiographic images |
949 |
923 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
641 |
626 |
$21K |
| D1110 |
Prophylaxis - adult |
362 |
358 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,033 |
1,983 |
$16K |
| D0272 |
Bitewings - two radiographic images |
747 |
743 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
192 |
95 |
$14K |
| D0330 |
Panoramic radiographic image |
438 |
424 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
80 |
$4K |
| D0603 |
|
2,501 |
2,484 |
$568.06 |
| D1330 |
|
73 |
68 |
$563.28 |