| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,479 |
579 |
$137K |
| D1351 |
Sealant - per tooth |
4,092 |
649 |
$103K |
| D1110 |
Prophylaxis - adult |
1,023 |
996 |
$52K |
| D1120 |
Prophylaxis - child |
1,430 |
1,385 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,468 |
1,430 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,587 |
1,542 |
$43K |
| D0145 |
Oral evaluation for a patient under three years of age |
313 |
307 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,586 |
2,502 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,658 |
2,553 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,814 |
2,409 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
962 |
910 |
$30K |
| D0272 |
Bitewings - two radiographic images |
766 |
742 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
61 |
$8K |
| D0350 |
|
396 |
381 |
$5K |
| D0601 |
|
309 |
306 |
$0.00 |
| D0602 |
|
2,632 |
2,562 |
$0.00 |