| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,298 |
1,315 |
$228K |
| D0120 |
Periodic oral evaluation - established patient |
3,801 |
3,704 |
$106K |
| D1120 |
Prophylaxis - child |
2,639 |
2,568 |
$93K |
| D1110 |
Prophylaxis - adult |
1,481 |
1,447 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,218 |
2,159 |
$64K |
| D1351 |
Sealant - per tooth |
2,360 |
737 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
797 |
487 |
$62K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
589 |
425 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,080 |
3,972 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
3,972 |
3,836 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,980 |
3,576 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,309 |
1,279 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
293 |
$18K |
| D0330 |
Panoramic radiographic image |
959 |
921 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
186 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
206 |
203 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
14 |
$2K |
| D0603 |
|
4,336 |
4,225 |
$0.00 |
| D0602 |
|
37 |
36 |
$0.00 |