| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,122 |
2,366 |
$402K |
| D1110 |
Prophylaxis - adult |
4,912 |
4,888 |
$265K |
| D0120 |
Periodic oral evaluation - established patient |
9,228 |
9,173 |
$261K |
| D1351 |
Sealant - per tooth |
8,716 |
2,424 |
$232K |
| D1120 |
Prophylaxis - child |
6,318 |
6,269 |
$227K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,456 |
1,529 |
$186K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,139 |
12,065 |
$175K |
| D0210 |
Intraoral - complete series of radiographic images |
1,723 |
1,710 |
$118K |
| D0274 |
Bitewings - four radiographic images |
3,397 |
3,380 |
$116K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,535 |
4,820 |
$108K |
| D0145 |
Oral evaluation for a patient under three years of age |
640 |
634 |
$89K |
| D0272 |
Bitewings - two radiographic images |
3,009 |
2,988 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,019 |
2,001 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
5,483 |
5,442 |
$67K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
117 |
54 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
115 |
53 |
$9K |
| D0603 |
|
10,669 |
10,569 |
$0.00 |
| D0602 |
|
2,374 |
2,352 |
$0.00 |