| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
1,196 |
662 |
$222K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
755 |
506 |
$120K |
| D1120 |
Prophylaxis - child |
1,940 |
1,940 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,876 |
1,876 |
$48K |
| D2332 |
|
334 |
234 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,810 |
1,810 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
442 |
240 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,406 |
1,406 |
$26K |
| D2335 |
|
202 |
155 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,895 |
1,889 |
$21K |
| D0274 |
Bitewings - four radiographic images |
660 |
660 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,842 |
1,814 |
$17K |
| D0330 |
Panoramic radiographic image |
295 |
295 |
$16K |
| D1110 |
Prophylaxis - adult |
399 |
399 |
$14K |
| D1206 |
Topical application of fluoride varnish |
432 |
432 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
223 |
$10K |
| D1351 |
Sealant - per tooth |
269 |
68 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
94 |
74 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
127 |
127 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
29 |
$4K |
| D2161 |
|
36 |
20 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
16 |
$3K |
| D2160 |
|
28 |
18 |
$2K |