| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,213 |
1,084 |
$266K |
| D1351 |
Sealant - per tooth |
6,948 |
1,492 |
$243K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,901 |
811 |
$191K |
| D1120 |
Prophylaxis - child |
2,799 |
2,778 |
$111K |
| D1206 |
Topical application of fluoride varnish |
4,052 |
4,014 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,864 |
1,848 |
$88K |
| D0272 |
Bitewings - two radiographic images |
1,285 |
1,271 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,148 |
1,131 |
$36K |
| D0274 |
Bitewings - four radiographic images |
811 |
811 |
$30K |
| D1110 |
Prophylaxis - adult |
396 |
396 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
877 |
858 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,207 |
459 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
351 |
272 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
41 |
$9K |
| D7111 |
|
74 |
42 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
102 |
102 |
$4K |
| D1330 |
|
96 |
96 |
$2K |
| D2330 |
|
23 |
13 |
$2K |
| D1353 |
|
58 |
31 |
$2K |
| D3120 |
|
45 |
26 |
$2K |
| D0240 |
|
26 |
13 |
$418.08 |