| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
678 |
365 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,249 |
2,210 |
$62K |
| D1110 |
Prophylaxis - adult |
844 |
834 |
$44K |
| D1120 |
Prophylaxis - child |
1,100 |
1,079 |
$38K |
| D1351 |
Sealant - per tooth |
1,432 |
325 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,636 |
2,197 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,288 |
2,254 |
$32K |
| D0274 |
Bitewings - four radiographic images |
940 |
928 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,366 |
2,310 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
149 |
147 |
$20K |
| D0272 |
Bitewings - two radiographic images |
516 |
505 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
38 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$847.68 |
| D0603 |
|
971 |
966 |
$0.00 |
| D0602 |
|
1,131 |
1,114 |
$0.00 |
| D0601 |
|
111 |
111 |
$0.00 |