| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,013 |
2,071 |
$354K |
| D1120 |
Prophylaxis - child |
5,122 |
5,120 |
$195K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,157 |
1,529 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
5,199 |
5,197 |
$136K |
| D1110 |
Prophylaxis - adult |
1,895 |
1,895 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,732 |
3,730 |
$82K |
| D1351 |
Sealant - per tooth |
2,711 |
521 |
$81K |
| D1206 |
Topical application of fluoride varnish |
2,495 |
2,493 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
3,684 |
3,627 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,690 |
1,690 |
$55K |
| D9920 |
|
796 |
761 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,393 |
1,391 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
673 |
672 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,067 |
2,777 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
556 |
540 |
$23K |
| D0330 |
Panoramic radiographic image |
294 |
294 |
$19K |
| D7111 |
|
247 |
186 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
150 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
76 |
70 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
45 |
40 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
13 |
$1K |