| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13,133 |
5,812 |
$955K |
| D0120 |
Periodic oral evaluation - established patient |
30,317 |
28,722 |
$656K |
| D1120 |
Prophylaxis - child |
20,341 |
19,273 |
$630K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
8,246 |
4,041 |
$562K |
| D1110 |
Prophylaxis - adult |
11,413 |
10,838 |
$482K |
| D1206 |
Topical application of fluoride varnish |
26,942 |
25,526 |
$479K |
| D7140 |
Extraction, erupted tooth or exposed root |
7,170 |
2,723 |
$462K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,532 |
759 |
$275K |
| D0272 |
Bitewings - two radiographic images |
9,127 |
8,619 |
$190K |
| D0274 |
Bitewings - four radiographic images |
6,244 |
5,896 |
$186K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,225 |
867 |
$177K |
| D0330 |
Panoramic radiographic image |
3,023 |
2,830 |
$152K |
| D0140 |
Limited oral evaluation - problem focused |
4,643 |
4,158 |
$127K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,952 |
2,689 |
$102K |
| D0220 |
Intraoral - periapical first radiographic image |
6,594 |
5,889 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,761 |
1,669 |
$50K |
| D1351 |
Sealant - per tooth |
2,041 |
462 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
539 |
326 |
$39K |
| D2332 |
|
179 |
72 |
$15K |
| D2330 |
|
75 |
41 |
$4K |
| D2331 |
|
21 |
14 |
$2K |
| D0270 |
|
13 |
13 |
$198.10 |