| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,221 |
2,213 |
$276K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,303 |
615 |
$74K |
| D1351 |
Sealant - per tooth |
659 |
167 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
636 |
363 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,001 |
482 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$8K |
| D2140 |
|
548 |
313 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
2,354 |
2,321 |
$6K |
| D1206 |
Topical application of fluoride varnish |
1,636 |
1,636 |
$2K |
| D1120 |
Prophylaxis - child |
1,846 |
1,840 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,397 |
1,359 |
$975.64 |
| D0272 |
Bitewings - two radiographic images |
901 |
901 |
$734.85 |
| D1110 |
Prophylaxis - adult |
40 |
38 |
$619.08 |
| D0274 |
Bitewings - four radiographic images |
606 |
602 |
$513.45 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$184.67 |
| D0603 |
|
195 |
183 |
$0.00 |
| D2160 |
|
17 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
174 |
174 |
$0.00 |
| D1999 |
|
143 |
143 |
$0.00 |