| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,043 |
856 |
$199K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
779 |
435 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,384 |
1,337 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,984 |
1,557 |
$43K |
| D1120 |
Prophylaxis - child |
1,022 |
986 |
$35K |
| D1351 |
Sealant - per tooth |
1,322 |
421 |
$33K |
| D0274 |
Bitewings - four radiographic images |
955 |
915 |
$31K |
| D1110 |
Prophylaxis - adult |
592 |
563 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,615 |
1,552 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,624 |
1,557 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
65 |
29 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
65 |
63 |
$9K |
| D0272 |
Bitewings - two radiographic images |
268 |
260 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
170 |
162 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0603 |
|
1,743 |
1,679 |
$0.00 |