| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,417 |
626 |
$172K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
753 |
374 |
$140K |
| D1120 |
Prophylaxis - child |
2,263 |
2,261 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,428 |
2,426 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
738 |
430 |
$69K |
| D1206 |
Topical application of fluoride varnish |
2,405 |
2,403 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
624 |
350 |
$52K |
| D0272 |
Bitewings - two radiographic images |
1,346 |
1,341 |
$35K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
241 |
144 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
323 |
$19K |
| D9248 |
|
249 |
245 |
$14K |
| D0240 |
|
379 |
356 |
$8K |
| D1110 |
Prophylaxis - adult |
124 |
124 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
234 |
232 |
$5K |
| D1351 |
Sealant - per tooth |
128 |
42 |
$4K |
| D2332 |
|
21 |
15 |
$3K |