| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,866 |
1,115 |
$372K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,803 |
1,004 |
$210K |
| D1351 |
Sealant - per tooth |
1,548 |
280 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,359 |
1,350 |
$36K |
| D1110 |
Prophylaxis - adult |
555 |
543 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,982 |
1,955 |
$27K |
| D1120 |
Prophylaxis - child |
740 |
731 |
$25K |
| D0145 |
Oral evaluation for a patient under three years of age |
168 |
168 |
$24K |
| D0274 |
Bitewings - four radiographic images |
660 |
651 |
$19K |
| D2331 |
|
192 |
70 |
$17K |
| D0272 |
Bitewings - two radiographic images |
748 |
740 |
$15K |
| D2332 |
|
95 |
46 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
40 |
$9K |
| D2330 |
|
108 |
48 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
222 |
218 |
$8K |
| D0330 |
Panoramic radiographic image |
155 |
153 |
$4K |
| D0601 |
|
551 |
547 |
$0.00 |
| D0602 |
|
414 |
411 |
$0.00 |
| D0603 |
|
548 |
540 |
$0.00 |