| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,093 |
516 |
$99K |
| D1351 |
Sealant - per tooth |
3,989 |
852 |
$98K |
| D1110 |
Prophylaxis - adult |
968 |
919 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,646 |
1,544 |
$44K |
| D1120 |
Prophylaxis - child |
1,254 |
1,182 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,101 |
2,352 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,158 |
1,107 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,359 |
2,236 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
2,555 |
2,422 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
600 |
590 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
140 |
126 |
$18K |
| D0272 |
Bitewings - two radiographic images |
589 |
559 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
44 |
$5K |
| D0603 |
|
2,950 |
2,786 |
$10.03 |