| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
244 |
164 |
$30K |
| D1120 |
Prophylaxis - child |
749 |
749 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
714 |
714 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
878 |
878 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
210 |
148 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
78 |
61 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
83 |
$10K |
| D1351 |
Sealant - per tooth |
243 |
107 |
$8K |
| D0272 |
Bitewings - two radiographic images |
264 |
264 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
43 |
36 |
$5K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
70 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
179 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
248 |
96 |
$3K |
| D0240 |
|
152 |
79 |
$3K |
| D2331 |
|
24 |
19 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$2K |
| D9920 |
|
19 |
18 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$516.00 |