| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
942 |
342 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
459 |
215 |
$35K |
| D1351 |
Sealant - per tooth |
1,236 |
338 |
$31K |
| D1120 |
Prophylaxis - child |
575 |
565 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
311 |
309 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
482 |
468 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
849 |
835 |
$12K |
| D1110 |
Prophylaxis - adult |
199 |
195 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
321 |
$10K |
| D0272 |
Bitewings - two radiographic images |
355 |
346 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
51 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
16 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
301 |
216 |
$3K |
| D0274 |
Bitewings - four radiographic images |
92 |
88 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
232 |
217 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
16 |
$3K |
| D0603 |
|
651 |
624 |
$0.00 |
| D0602 |
|
105 |
103 |
$0.00 |
| D0601 |
|
148 |
143 |
$0.00 |