| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,708 |
595 |
$173K |
| D1351 |
Sealant - per tooth |
2,894 |
713 |
$80K |
| D1120 |
Prophylaxis - child |
1,299 |
1,299 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,539 |
1,539 |
$44K |
| D1110 |
Prophylaxis - adult |
804 |
804 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,153 |
2,153 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
388 |
177 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,826 |
1,817 |
$22K |
| D0272 |
Bitewings - two radiographic images |
863 |
863 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,743 |
1,703 |
$20K |
| D0274 |
Bitewings - four radiographic images |
517 |
517 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
214 |
214 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
356 |
356 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
63 |
63 |
$9K |
| D0603 |
|
2,389 |
2,388 |
$0.00 |