| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,096 |
1,585 |
$399K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,808 |
951 |
$136K |
| D1351 |
Sealant - per tooth |
3,307 |
868 |
$86K |
| D1120 |
Prophylaxis - child |
1,665 |
1,640 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,473 |
1,451 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,277 |
1,256 |
$42K |
| D1110 |
Prophylaxis - adult |
789 |
777 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,607 |
2,567 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,333 |
2,505 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,573 |
2,526 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,046 |
1,030 |
$29K |
| D0145 |
Oral evaluation for a patient under three years of age |
216 |
214 |
$29K |
| D0272 |
Bitewings - two radiographic images |
927 |
914 |
$21K |
| D0350 |
|
1,252 |
1,227 |
$19K |
| D2330 |
|
136 |
70 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
17 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
194 |
192 |
$5K |
| D2331 |
|
44 |
38 |
$4K |
| D1330 |
|
17 |
16 |
$85.75 |
| D0603 |
|
2,340 |
2,308 |
$0.00 |
| D0602 |
|
387 |
384 |
$0.00 |
| D0601 |
|
106 |
105 |
$0.00 |