| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,970 |
3,968 |
$185K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,229 |
1,602 |
$148K |
| D1110 |
Prophylaxis - adult |
1,406 |
1,406 |
$116K |
| D1120 |
Prophylaxis - child |
3,391 |
3,387 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,883 |
1,317 |
$101K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,683 |
4,679 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
879 |
878 |
$52K |
| D0350 |
|
4,991 |
2,677 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,963 |
1,962 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
458 |
372 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,348 |
3,476 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
686 |
686 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,229 |
2,173 |
$26K |
| D1351 |
Sealant - per tooth |
824 |
304 |
$19K |
| D2330 |
|
135 |
90 |
$10K |
| D0272 |
Bitewings - two radiographic images |
620 |
620 |
$7K |
| D9430 |
|
133 |
132 |
$4K |
| D7111 |
|
65 |
53 |
$4K |
| D4341 |
|
32 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$452.50 |