| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
563 |
326 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,115 |
2,115 |
$61K |
| D1120 |
Prophylaxis - child |
1,861 |
1,861 |
$56K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
402 |
183 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,579 |
1,579 |
$31K |
| D0274 |
Bitewings - four radiographic images |
910 |
910 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,316 |
1,316 |
$26K |
| D1110 |
Prophylaxis - adult |
526 |
526 |
$22K |
| D1206 |
Topical application of fluoride varnish |
692 |
692 |
$18K |
| D1351 |
Sealant - per tooth |
584 |
208 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
45 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
246 |
244 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
436 |
433 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
57 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
190 |
190 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
15 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
37 |
37 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$786.24 |