| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
533 |
187 |
$43K |
| D1351 |
Sealant - per tooth |
1,141 |
239 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,272 |
828 |
$22K |
| D1120 |
Prophylaxis - child |
618 |
594 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
743 |
716 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,003 |
967 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
989 |
934 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
39 |
$6K |
| D0272 |
Bitewings - two radiographic images |
218 |
208 |
$4K |
| D1110 |
Prophylaxis - adult |
101 |
93 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
65 |
$2K |
| D0274 |
Bitewings - four radiographic images |
99 |
89 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0603 |
|
808 |
790 |
$0.00 |
| D0602 |
|
225 |
221 |
$0.00 |