| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,058 |
488 |
$208K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,883 |
3,376 |
$122K |
| D1351 |
Sealant - per tooth |
4,451 |
581 |
$121K |
| D0145 |
Oral evaluation for a patient under three years of age |
692 |
682 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,280 |
3,233 |
$93K |
| D1120 |
Prophylaxis - child |
2,484 |
2,435 |
$89K |
| D1110 |
Prophylaxis - adult |
1,196 |
1,183 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,655 |
3,594 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,540 |
1,527 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
3,693 |
3,616 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
311 |
122 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
30 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
249 |
240 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
45 |
39 |
$888.44 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$450.72 |
| D0603 |
|
2,770 |
2,736 |
$0.39 |
| D0601 |
|
1,637 |
1,606 |
$0.01 |