| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
313 |
95 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,932 |
584 |
$20K |
| D1351 |
Sealant - per tooth |
709 |
124 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
425 |
$15K |
| D1120 |
Prophylaxis - child |
366 |
363 |
$13K |
| D1110 |
Prophylaxis - adult |
177 |
170 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
822 |
800 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
59 |
54 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
269 |
266 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
507 |
504 |
$7K |
| D0272 |
Bitewings - two radiographic images |
257 |
253 |
$5K |
| D1206 |
Topical application of fluoride varnish |
188 |
180 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$761.64 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$719.62 |
| D0603 |
|
1,255 |
1,230 |
$107.28 |