| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
369 |
182 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
784 |
769 |
$19K |
| D1120 |
Prophylaxis - child |
526 |
509 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,531 |
748 |
$14K |
| D1351 |
Sealant - per tooth |
564 |
112 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
955 |
933 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
856 |
835 |
$9K |
| D0274 |
Bitewings - four radiographic images |
414 |
406 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
56 |
55 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
55 |
$6K |
| D0272 |
Bitewings - two radiographic images |
175 |
172 |
$4K |
| D1110 |
Prophylaxis - adult |
39 |
36 |
$2K |
| D0601 |
|
463 |
450 |
$0.00 |
| D0603 |
|
327 |
322 |
$0.00 |
| D0602 |
|
53 |
49 |
$0.00 |
| D1330 |
|
15 |
14 |
$0.00 |