| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,537 |
895 |
$185K |
| D1120 |
Prophylaxis - child |
3,597 |
3,597 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
3,726 |
3,725 |
$126K |
| D1206 |
Topical application of fluoride varnish |
3,823 |
3,823 |
$109K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,081 |
566 |
$94K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
413 |
317 |
$61K |
| D1351 |
Sealant - per tooth |
1,642 |
381 |
$54K |
| D1110 |
Prophylaxis - adult |
590 |
590 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
357 |
357 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,182 |
1,182 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
143 |
66 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
950 |
944 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
252 |
252 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
168 |
99 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
807 |
460 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
162 |
$10K |
| D1354 |
|
225 |
65 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
191 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$1K |
| D9986 |
|
138 |
137 |
$0.00 |