| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,927 |
1,157 |
$203K |
| D1120 |
Prophylaxis - child |
4,091 |
4,087 |
$152K |
| D0120 |
Periodic oral evaluation - established patient |
4,721 |
4,719 |
$139K |
| D1206 |
Topical application of fluoride varnish |
4,395 |
4,391 |
$109K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,206 |
789 |
$100K |
| D7140 |
Extraction, erupted tooth or exposed root |
502 |
308 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,634 |
1,631 |
$36K |
| D1110 |
Prophylaxis - adult |
503 |
502 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
78 |
49 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
228 |
$12K |
| D1351 |
Sealant - per tooth |
365 |
157 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
26 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
46 |
$3K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
70 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$902.00 |
| D0240 |
|
29 |
28 |
$560.00 |