| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
277 |
101 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
424 |
342 |
$4K |
| D1110 |
Prophylaxis - adult |
184 |
150 |
$4K |
| D1351 |
Sealant - per tooth |
297 |
86 |
$4K |
| D0274 |
Bitewings - four radiographic images |
253 |
209 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
46 |
41 |
$3K |
| D1120 |
Prophylaxis - child |
201 |
161 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
29 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
408 |
330 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
439 |
352 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
434 |
344 |
$2K |
| D0272 |
Bitewings - two radiographic images |
159 |
117 |
$1K |
| D0603 |
|
522 |
428 |
$0.00 |