| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,597 |
819 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
2,911 |
2,888 |
$79K |
| D0145 |
Oral evaluation for a patient under three years of age |
446 |
443 |
$61K |
| D1120 |
Prophylaxis - child |
1,452 |
1,437 |
$50K |
| D1110 |
Prophylaxis - adult |
904 |
899 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,425 |
1,420 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,108 |
2,623 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,477 |
2,457 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
457 |
277 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,842 |
2,791 |
$29K |
| D1351 |
Sealant - per tooth |
730 |
133 |
$19K |
| D0272 |
Bitewings - two radiographic images |
786 |
776 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
176 |
$12K |
| D0330 |
Panoramic radiographic image |
219 |
219 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
106 |
$3K |
| D0350 |
|
134 |
134 |
$1K |
| D4355 |
|
12 |
12 |
$859.92 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$225.36 |
| D0603 |
|
3,398 |
3,385 |
$0.00 |
| D0602 |
|
213 |
211 |
$0.00 |
| D1999 |
|
942 |
834 |
$0.00 |