| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,904 |
1,230 |
$390K |
| D0145 |
Oral evaluation for a patient under three years of age |
851 |
820 |
$114K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,337 |
486 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,077 |
3,030 |
$87K |
| D1120 |
Prophylaxis - child |
2,087 |
2,053 |
$74K |
| D1351 |
Sealant - per tooth |
2,789 |
756 |
$73K |
| D1110 |
Prophylaxis - adult |
1,186 |
1,167 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,360 |
3,306 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,155 |
1,137 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,168 |
1,157 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,198 |
659 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
77 |
25 |
$11K |
| D0330 |
Panoramic radiographic image |
466 |
453 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
884 |
839 |
$10K |
| D2332 |
|
74 |
29 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
122 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
71 |
24 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$920.22 |
| D0601 |
|
1,045 |
1,009 |
$0.12 |
| D0603 |
|
2,149 |
2,112 |
$0.11 |
| D0602 |
|
877 |
868 |
$0.05 |