| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
762 |
373 |
$95K |
| D1120 |
Prophylaxis - child |
1,185 |
1,184 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,500 |
1,499 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
351 |
220 |
$33K |
| D1110 |
Prophylaxis - adult |
517 |
517 |
$26K |
| D1206 |
Topical application of fluoride varnish |
937 |
937 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,265 |
1,245 |
$20K |
| D0274 |
Bitewings - four radiographic images |
562 |
562 |
$19K |
| D1351 |
Sealant - per tooth |
424 |
108 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
43 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
243 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
443 |
442 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
216 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,016 |
989 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
28 |
$8K |
| D2950 |
|
44 |
40 |
$7K |
| D0272 |
Bitewings - two radiographic images |
298 |
298 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
50 |
28 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
24 |
$3K |
| D0350 |
|
25 |
25 |
$367.60 |
| D0602 |
|
81 |
81 |
$0.00 |