| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
792 |
774 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
3,483 |
3,464 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
883 |
591 |
$90K |
| D1110 |
Prophylaxis - adult |
1,539 |
1,533 |
$83K |
| D1120 |
Prophylaxis - child |
2,044 |
2,031 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
927 |
546 |
$72K |
| D1351 |
Sealant - per tooth |
2,545 |
761 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,634 |
3,615 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,520 |
1,514 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,211 |
3,405 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
3,653 |
3,588 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,543 |
1,535 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
181 |
139 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
84 |
54 |
$13K |
| D0350 |
|
514 |
510 |
$8K |
| D0330 |
Panoramic radiographic image |
380 |
374 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$2K |
| D0603 |
|
2,628 |
2,616 |
$0.00 |
| D0601 |
|
776 |
757 |
$0.00 |
| D0602 |
|
886 |
882 |
$0.00 |