| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,317 |
901 |
$216K |
| D0120 |
Periodic oral evaluation - established patient |
6,097 |
5,967 |
$171K |
| D1110 |
Prophylaxis - adult |
2,557 |
2,506 |
$136K |
| D0145 |
Oral evaluation for a patient under three years of age |
952 |
935 |
$130K |
| D1120 |
Prophylaxis - child |
3,649 |
3,562 |
$129K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,380 |
444 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,212 |
6,079 |
$89K |
| D0274 |
Bitewings - four radiographic images |
2,541 |
2,491 |
$80K |
| D0272 |
Bitewings - two radiographic images |
3,343 |
3,269 |
$72K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
164 |
101 |
$23K |
| D0330 |
Panoramic radiographic image |
756 |
746 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
178 |
112 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
171 |
171 |
$12K |
| D1351 |
Sealant - per tooth |
124 |
15 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
50 |
$957.78 |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
70 |
$866.64 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
19 |
$218.69 |
| D0602 |
|
304 |
294 |
$0.00 |
| D0603 |
|
5,692 |
5,575 |
$0.00 |
| D0601 |
|
969 |
945 |
$0.00 |
| D9986 |
|
53 |
53 |
$0.00 |