| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,488 |
608 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
4,375 |
4,327 |
$123K |
| D1351 |
Sealant - per tooth |
5,096 |
750 |
$117K |
| D1110 |
Prophylaxis - adult |
1,834 |
1,813 |
$98K |
| D1120 |
Prophylaxis - child |
2,442 |
2,412 |
$87K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,910 |
4,853 |
$70K |
| D0274 |
Bitewings - four radiographic images |
1,973 |
1,943 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
4,453 |
4,392 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
709 |
198 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,387 |
4,131 |
$49K |
| D0272 |
Bitewings - two radiographic images |
1,747 |
1,735 |
$40K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
65 |
$2K |
| D1206 |
Topical application of fluoride varnish |
37 |
36 |
$528.91 |
| D1330 |
|
64 |
57 |
$514.50 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$146.16 |
| D0602 |
|
239 |
239 |
$0.00 |
| D0603 |
|
3,642 |
3,620 |
$0.00 |
| D0601 |
|
904 |
891 |
$0.00 |