| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,880 |
797 |
$138K |
| D1110 |
Prophylaxis - adult |
2,058 |
2,013 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
901 |
417 |
$82K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,192 |
2,153 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,571 |
1,539 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,751 |
1,720 |
$35K |
| D0330 |
Panoramic radiographic image |
787 |
664 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,221 |
1,012 |
$32K |
| D1120 |
Prophylaxis - child |
626 |
614 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,206 |
894 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
720 |
486 |
$7K |
| D1351 |
Sealant - per tooth |
196 |
54 |
$6K |
| D9310 |
|
67 |
61 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
80 |
$4K |
| D9920 |
|
52 |
48 |
$4K |
| D3120 |
|
157 |
79 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
27 |
$670.41 |
| D1999 |
|
21 |
16 |
$0.00 |