| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,537 |
1,102 |
$256K |
| D1351 |
Sealant - per tooth |
4,056 |
744 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
3,022 |
3,013 |
$86K |
| D1120 |
Prophylaxis - child |
1,822 |
1,816 |
$66K |
| D1110 |
Prophylaxis - adult |
1,070 |
1,066 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,305 |
3,291 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,279 |
1,276 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,764 |
2,744 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,649 |
2,591 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
404 |
402 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
184 |
184 |
$26K |
| D0272 |
Bitewings - two radiographic images |
715 |
710 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
39 |
$6K |
| D0603 |
|
3,854 |
3,832 |
$0.00 |