| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,736 |
722 |
$256K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,965 |
620 |
$142K |
| D1351 |
Sealant - per tooth |
1,197 |
212 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
778 |
773 |
$21K |
| D1110 |
Prophylaxis - adult |
345 |
343 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,013 |
1,006 |
$14K |
| D1120 |
Prophylaxis - child |
350 |
347 |
$12K |
| D2331 |
|
139 |
66 |
$12K |
| D0274 |
Bitewings - four radiographic images |
404 |
399 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
88 |
86 |
$12K |
| D0272 |
Bitewings - two radiographic images |
351 |
348 |
$7K |
| D2330 |
|
85 |
41 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
89 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
14 |
$2K |
| D2332 |
|
17 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$1K |
| D0603 |
|
597 |
591 |
$0.00 |
| D0601 |
|
158 |
156 |
$0.00 |
| D0602 |
|
128 |
125 |
$0.00 |