| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,399 |
604 |
$140K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,647 |
3,942 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
3,830 |
3,786 |
$108K |
| D1351 |
Sealant - per tooth |
3,922 |
958 |
$106K |
| D1120 |
Prophylaxis - child |
2,405 |
2,367 |
$86K |
| D0274 |
Bitewings - four radiographic images |
2,156 |
2,141 |
$73K |
| D1110 |
Prophylaxis - adult |
1,342 |
1,327 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,083 |
4,028 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
4,143 |
4,082 |
$50K |
| D0145 |
Oral evaluation for a patient under three years of age |
302 |
297 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
197 |
116 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
56 |
25 |
$8K |
| D0272 |
Bitewings - two radiographic images |
339 |
333 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$914.79 |
| D0603 |
|
4,883 |
4,825 |
$0.03 |