| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
932 |
441 |
$91K |
| D1351 |
Sealant - per tooth |
2,553 |
546 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
851 |
$24K |
| D1110 |
Prophylaxis - adult |
378 |
374 |
$20K |
| D1120 |
Prophylaxis - child |
543 |
541 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,663 |
1,020 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,010 |
1,005 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,061 |
1,051 |
$12K |
| D0274 |
Bitewings - four radiographic images |
373 |
369 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
64 |
62 |
$9K |
| D0272 |
Bitewings - two radiographic images |
380 |
379 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
50 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$1K |
| D0603 |
|
1,222 |
1,206 |
$0.00 |