| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,954 |
813 |
$296K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
765 |
425 |
$58K |
| D1351 |
Sealant - per tooth |
1,731 |
451 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
786 |
771 |
$27K |
| D1120 |
Prophylaxis - child |
659 |
650 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
311 |
311 |
$22K |
| D1110 |
Prophylaxis - adult |
351 |
344 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,236 |
1,207 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,907 |
1,261 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
112 |
110 |
$16K |
| D0274 |
Bitewings - four radiographic images |
534 |
516 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,312 |
1,271 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
293 |
290 |
$8K |
| D0330 |
Panoramic radiographic image |
762 |
748 |
$8K |
| D0272 |
Bitewings - two radiographic images |
455 |
449 |
$6K |
| D0603 |
|
661 |
649 |
$0.00 |
| D0602 |
|
400 |
397 |
$0.00 |
| D0601 |
|
107 |
106 |
$0.00 |