| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,387 |
652 |
$170K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
648 |
337 |
$124K |
| D1120 |
Prophylaxis - child |
2,295 |
2,293 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,409 |
2,407 |
$80K |
| D1206 |
Topical application of fluoride varnish |
2,434 |
2,431 |
$67K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
483 |
266 |
$60K |
| D7140 |
Extraction, erupted tooth or exposed root |
571 |
304 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
478 |
292 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,313 |
1,310 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
425 |
425 |
$26K |
| D9248 |
|
265 |
264 |
$15K |
| D0240 |
|
493 |
455 |
$10K |
| D1110 |
Prophylaxis - adult |
147 |
147 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
406 |
406 |
$7K |
| D2330 |
|
85 |
51 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
25 |
$5K |
| D1351 |
Sealant - per tooth |
130 |
41 |
$4K |
| D2332 |
|
16 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
137 |
70 |
$2K |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |