| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,005 |
471 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
2,872 |
2,812 |
$79K |
| D1351 |
Sealant - per tooth |
3,048 |
844 |
$78K |
| D1110 |
Prophylaxis - adult |
1,290 |
1,267 |
$67K |
| D1120 |
Prophylaxis - child |
1,674 |
1,635 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,422 |
1,391 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,172 |
3,103 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
379 |
197 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
411 |
404 |
$26K |
| D0272 |
Bitewings - two radiographic images |
724 |
706 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,339 |
1,297 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
115 |
109 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,151 |
1,114 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
98 |
$3K |
| D1330 |
|
28 |
27 |
$318.50 |
| D0603 |
|
3,597 |
3,530 |
$0.00 |