| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,057 |
489 |
$67K |
| D1351 |
Sealant - per tooth |
2,528 |
733 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
903 |
465 |
$44K |
| D1120 |
Prophylaxis - child |
2,033 |
2,010 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,003 |
996 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,265 |
1,247 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,973 |
1,961 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,689 |
1,668 |
$22K |
| D0274 |
Bitewings - four radiographic images |
213 |
212 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
202 |
200 |
$4K |
| D1110 |
Prophylaxis - adult |
112 |
111 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
218 |
206 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
28 |
$265.00 |