| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,036 |
425 |
$101K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,007 |
400 |
$77K |
| D2330 |
|
460 |
226 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
810 |
783 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,812 |
780 |
$20K |
| D1120 |
Prophylaxis - child |
569 |
544 |
$20K |
| D1351 |
Sealant - per tooth |
832 |
231 |
$18K |
| D0274 |
Bitewings - four radiographic images |
540 |
488 |
$15K |
| D1110 |
Prophylaxis - adult |
234 |
233 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
808 |
782 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
73 |
45 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
810 |
781 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
51 |
50 |
$1K |
| D1330 |
|
267 |
244 |
$673.75 |
| D7111 |
|
51 |
31 |
$573.50 |
| D0602 |
|
903 |
831 |
$0.00 |