| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
96 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
166 |
165 |
$23K |
| D1351 |
Sealant - per tooth |
852 |
187 |
$23K |
| D1120 |
Prophylaxis - child |
259 |
256 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
51 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
234 |
232 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
339 |
336 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
134 |
$5K |
| D0272 |
Bitewings - two radiographic images |
146 |
143 |
$3K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$3K |
| D0274 |
Bitewings - four radiographic images |
164 |
164 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
512 |
156 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
194 |
$1K |
| D0603 |
|
658 |
650 |
$27.33 |