| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
10,666 |
2,303 |
$779K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,672 |
1,878 |
$525K |
| D1120 |
Prophylaxis - child |
2,606 |
2,469 |
$88K |
| D1110 |
Prophylaxis - adult |
1,564 |
1,477 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,440 |
2,295 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,300 |
4,073 |
$58K |
| D0272 |
Bitewings - two radiographic images |
2,357 |
2,248 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,648 |
1,557 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,775 |
1,693 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
3,961 |
3,750 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,977 |
3,735 |
$43K |
| D1351 |
Sealant - per tooth |
1,582 |
475 |
$41K |
| D0145 |
Oral evaluation for a patient under three years of age |
187 |
175 |
$22K |
| D2332 |
|
24 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
14 |
$870.84 |
| D0603 |
|
4,704 |
4,451 |
$0.00 |