| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
374 |
98 |
$36K |
| D1351 |
Sealant - per tooth |
1,301 |
227 |
$33K |
| D1120 |
Prophylaxis - child |
779 |
763 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
862 |
840 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,463 |
1,088 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,310 |
1,250 |
$15K |
| D1206 |
Topical application of fluoride varnish |
1,002 |
986 |
$14K |
| D0272 |
Bitewings - two radiographic images |
572 |
561 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
51 |
50 |
$7K |
| D1110 |
Prophylaxis - adult |
137 |
134 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
139 |
$5K |
| D0274 |
Bitewings - four radiographic images |
136 |
127 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
55 |
$793.80 |
| D0603 |
|
1,178 |
1,146 |
$0.01 |
| D0601 |
|
215 |
209 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |