| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,913 |
874 |
$182K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,237 |
567 |
$93K |
| D1351 |
Sealant - per tooth |
3,485 |
1,026 |
$84K |
| D1120 |
Prophylaxis - child |
1,831 |
1,766 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,530 |
1,481 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
278 |
108 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,901 |
865 |
$39K |
| D1110 |
Prophylaxis - adult |
659 |
642 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
655 |
639 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,014 |
986 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,005 |
1,948 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
275 |
107 |
$22K |
| D0272 |
Bitewings - two radiographic images |
819 |
804 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
94 |
94 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
135 |
94 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
908 |
857 |
$10K |
| D0274 |
Bitewings - four radiographic images |
283 |
276 |
$8K |
| D0330 |
Panoramic radiographic image |
244 |
237 |
$8K |
| D1206 |
Topical application of fluoride varnish |
530 |
508 |
$7K |
| D2330 |
|
81 |
49 |
$6K |
| D0602 |
|
400 |
389 |
$0.00 |
| D0603 |
|
1,841 |
1,745 |
$0.00 |
| D0601 |
|
580 |
559 |
$0.00 |