| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
934 |
360 |
$87K |
| D1351 |
Sealant - per tooth |
2,052 |
312 |
$51K |
| D1110 |
Prophylaxis - adult |
741 |
706 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,461 |
1,578 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,246 |
1,166 |
$32K |
| D1120 |
Prophylaxis - child |
947 |
897 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
447 |
77 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,923 |
1,816 |
$25K |
| D0274 |
Bitewings - four radiographic images |
748 |
687 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
672 |
632 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,830 |
1,697 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
55 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
121 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
25 |
$4K |
| D0272 |
Bitewings - two radiographic images |
71 |
67 |
$1K |
| D0603 |
|
2,146 |
2,004 |
$0.09 |
| D0601 |
|
40 |
40 |
$0.00 |
| D0602 |
|
70 |
70 |
$0.00 |