| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
940 |
390 |
$64K |
| D1120 |
Prophylaxis - child |
1,156 |
1,152 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,559 |
1,549 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,409 |
1,404 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
228 |
94 |
$27K |
| D1351 |
Sealant - per tooth |
828 |
195 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
303 |
153 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
128 |
$12K |
| D1110 |
Prophylaxis - adult |
249 |
248 |
$11K |
| D0272 |
Bitewings - two radiographic images |
473 |
472 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
111 |
63 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
98 |
$5K |
| D0274 |
Bitewings - four radiographic images |
145 |
145 |
$5K |
| D1330 |
|
742 |
741 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
42 |
$5K |
| D0603 |
|
427 |
426 |
$4K |
| D1310 |
|
211 |
211 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
46 |
$1K |
| D0240 |
|
23 |
15 |
$433.80 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$288.48 |
| D0602 |
|
27 |
27 |
$270.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
14 |
$90.80 |