| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,707 |
974 |
$274K |
| D1351 |
Sealant - per tooth |
4,111 |
1,038 |
$109K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,180 |
459 |
$86K |
| D1120 |
Prophylaxis - child |
1,809 |
1,774 |
$65K |
| D1110 |
Prophylaxis - adult |
1,200 |
1,169 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,218 |
2,174 |
$62K |
| D0145 |
Oral evaluation for a patient under three years of age |
328 |
324 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,044 |
2,977 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
2,625 |
2,559 |
$32K |
| D0274 |
Bitewings - four radiographic images |
900 |
875 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,230 |
1,219 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,491 |
2,374 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
357 |
350 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
696 |
678 |
$23K |
| D1330 |
|
13 |
12 |
$134.75 |
| D0603 |
|
3,458 |
3,365 |
$0.00 |
| D1999 |
|
1,514 |
1,495 |
$0.00 |