| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
500 |
207 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
702 |
652 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
137 |
135 |
$18K |
| D1120 |
Prophylaxis - child |
444 |
403 |
$14K |
| D1110 |
Prophylaxis - adult |
263 |
252 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
722 |
671 |
$10K |
| D0274 |
Bitewings - four radiographic images |
273 |
261 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
63 |
$8K |
| D1351 |
Sealant - per tooth |
311 |
77 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
610 |
188 |
$6K |
| D0272 |
Bitewings - two radiographic images |
271 |
240 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
423 |
382 |
$5K |
| D0603 |
|
552 |
508 |
$0.00 |
| D0601 |
|
224 |
215 |
$0.00 |
| D0602 |
|
59 |
59 |
$0.00 |