| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,904 |
806 |
$192K |
| D1351 |
Sealant - per tooth |
2,688 |
482 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,214 |
2,201 |
$63K |
| D1120 |
Prophylaxis - child |
1,430 |
1,419 |
$52K |
| D1110 |
Prophylaxis - adult |
882 |
880 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,078 |
1,074 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,379 |
2,365 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
194 |
194 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,066 |
2,043 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,962 |
1,918 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
324 |
322 |
$22K |
| D0272 |
Bitewings - two radiographic images |
567 |
564 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
13 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
13 |
$2K |
| D0603 |
|
2,785 |
2,766 |
$0.00 |