| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,284 |
579 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
1,515 |
1,485 |
$42K |
| D1110 |
Prophylaxis - adult |
762 |
750 |
$40K |
| D1351 |
Sealant - per tooth |
1,237 |
342 |
$33K |
| D1120 |
Prophylaxis - child |
899 |
889 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,917 |
1,894 |
$27K |
| D0274 |
Bitewings - four radiographic images |
829 |
810 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,605 |
1,557 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
254 |
252 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,481 |
1,443 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
112 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
210 |
207 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
27 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$6K |
| D0272 |
Bitewings - two radiographic images |
246 |
243 |
$6K |
| D0603 |
|
2,493 |
2,475 |
$0.00 |