| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,330 |
2,771 |
$535K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,245 |
3,208 |
$497K |
| D0120 |
Periodic oral evaluation - established patient |
12,543 |
12,543 |
$425K |
| D1351 |
Sealant - per tooth |
12,710 |
2,980 |
$425K |
| D1120 |
Prophylaxis - child |
9,993 |
9,992 |
$424K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,179 |
1,256 |
$402K |
| D1206 |
Topical application of fluoride varnish |
12,221 |
12,221 |
$348K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,318 |
1,465 |
$203K |
| D1110 |
Prophylaxis - adult |
3,472 |
3,472 |
$189K |
| D0210 |
Intraoral - complete series of radiographic images |
1,612 |
1,611 |
$133K |
| D0272 |
Bitewings - two radiographic images |
4,665 |
4,665 |
$120K |
| D1354 |
|
2,961 |
1,417 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
4,144 |
4,102 |
$77K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,090 |
2,182 |
$69K |
| D0140 |
Limited oral evaluation - problem focused |
1,144 |
1,126 |
$69K |
| D0274 |
Bitewings - four radiographic images |
1,382 |
1,382 |
$56K |
| D0240 |
|
2,322 |
1,512 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
823 |
823 |
$45K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
155 |
120 |
$20K |
| D2330 |
|
136 |
94 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
181 |
181 |
$7K |
| D9248 |
|
76 |
75 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
24 |
$4K |
| D2331 |
|
25 |
14 |
$2K |