| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,116 |
1,320 |
$314K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,536 |
874 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,162 |
2,132 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,129 |
2,539 |
$69K |
| D1120 |
Prophylaxis - child |
1,573 |
1,556 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,561 |
1,537 |
$53K |
| D1110 |
Prophylaxis - adult |
981 |
968 |
$52K |
| D1351 |
Sealant - per tooth |
2,000 |
707 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,583 |
2,550 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
2,579 |
2,545 |
$32K |
| D0145 |
Oral evaluation for a patient under three years of age |
134 |
130 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
385 |
383 |
$11K |
| D0272 |
Bitewings - two radiographic images |
460 |
454 |
$10K |
| D2330 |
|
111 |
57 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
13 |
$3K |
| D0603 |
|
2,853 |
2,807 |
$0.00 |