| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,150 |
1,203 |
$166K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,356 |
909 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
2,816 |
2,812 |
$81K |
| D1110 |
Prophylaxis - adult |
1,299 |
1,297 |
$69K |
| D1120 |
Prophylaxis - child |
1,600 |
1,597 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,678 |
1,676 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,953 |
2,949 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,955 |
2,946 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,052 |
2,876 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
138 |
138 |
$19K |
| D0272 |
Bitewings - two radiographic images |
666 |
665 |
$15K |
| D1351 |
Sealant - per tooth |
89 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0603 |
|
3,295 |
3,291 |
$0.00 |