| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,503 |
506 |
$143K |
| D0120 |
Periodic oral evaluation - established patient |
912 |
875 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,353 |
992 |
$24K |
| D1351 |
Sealant - per tooth |
821 |
206 |
$21K |
| D1120 |
Prophylaxis - child |
583 |
559 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,017 |
983 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
178 |
89 |
$13K |
| D1110 |
Prophylaxis - adult |
262 |
253 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,091 |
1,026 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
129 |
67 |
$12K |
| D0274 |
Bitewings - four radiographic images |
394 |
375 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
32 |
28 |
$4K |
| D0272 |
Bitewings - two radiographic images |
145 |
142 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$500.16 |
| D0603 |
|
1,070 |
1,030 |
$0.00 |
| D0602 |
|
15 |
15 |
$0.00 |