| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
5,999 |
1,210 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,200 |
539 |
$73K |
| D1351 |
Sealant - per tooth |
1,669 |
398 |
$57K |
| D2332 |
|
830 |
510 |
$57K |
| D2335 |
|
447 |
255 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,027 |
447 |
$40K |
| D1120 |
Prophylaxis - child |
1,113 |
1,112 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,478 |
1,457 |
$35K |
| D2331 |
|
620 |
365 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
804 |
804 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
493 |
492 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
837 |
831 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
874 |
865 |
$9K |
| D0272 |
Bitewings - two radiographic images |
576 |
575 |
$7K |
| D0274 |
Bitewings - four radiographic images |
175 |
175 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
39 |
$3K |
| D2330 |
|
105 |
86 |
$3K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
64 |
64 |
$2K |
| D0250 |
|
60 |
54 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$932.97 |
| D0251 |
|
58 |
55 |
$543.20 |
| D1320 |
|
20 |
20 |
$160.00 |