| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,195 |
927 |
$220K |
| D1351 |
Sealant - per tooth |
3,756 |
963 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
2,265 |
2,238 |
$64K |
| D0145 |
Oral evaluation for a patient under three years of age |
431 |
431 |
$61K |
| D1120 |
Prophylaxis - child |
1,596 |
1,579 |
$57K |
| D1110 |
Prophylaxis - adult |
702 |
691 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
459 |
300 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,451 |
2,422 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,264 |
514 |
$25K |
| D0274 |
Bitewings - four radiographic images |
683 |
673 |
$21K |
| D0272 |
Bitewings - two radiographic images |
946 |
936 |
$19K |
| D0330 |
Panoramic radiographic image |
432 |
424 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
666 |
655 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
68 |
$5K |
| D2332 |
|
24 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$244.14 |
| D0603 |
|
2,012 |
2,002 |
$0.00 |
| D0601 |
|
788 |
782 |
$0.00 |
| D0602 |
|
48 |
47 |
$0.00 |