| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,129 |
493 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
2,728 |
2,662 |
$75K |
| D0274 |
Bitewings - four radiographic images |
1,600 |
1,547 |
$52K |
| D1110 |
Prophylaxis - adult |
903 |
874 |
$46K |
| D1120 |
Prophylaxis - child |
1,334 |
1,298 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,035 |
2,953 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,214 |
3,113 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,525 |
2,988 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
149 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
71 |
68 |
$10K |
| D1351 |
Sealant - per tooth |
352 |
93 |
$9K |
| D0272 |
Bitewings - two radiographic images |
269 |
258 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
53 |
$2K |
| D0603 |
|
3,574 |
3,451 |
$9.00 |
| D0602 |
|
33 |
33 |
$0.00 |