| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,620 |
1,127 |
$416K |
| D1351 |
Sealant - per tooth |
9,592 |
1,188 |
$218K |
| D1120 |
Prophylaxis - child |
5,952 |
5,234 |
$142K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,624 |
2,251 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
3,304 |
2,962 |
$78K |
| D0274 |
Bitewings - four radiographic images |
3,829 |
3,298 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
1,704 |
1,547 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,271 |
3,651 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
484 |
172 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,641 |
1,538 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,017 |
522 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
213 |
181 |
$12K |
| D0350 |
|
275 |
273 |
$9K |
| D0272 |
Bitewings - two radiographic images |
449 |
412 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
597 |
549 |
$7K |
| D1110 |
Prophylaxis - adult |
21 |
21 |
$69.72 |
| D1203 |
|
29 |
28 |
$0.00 |