| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
614 |
353 |
$30K |
| D1120 |
Prophylaxis - child |
713 |
713 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
613 |
613 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
242 |
172 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
710 |
710 |
$7K |
| D0274 |
Bitewings - four radiographic images |
292 |
292 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
723 |
714 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
32 |
28 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
635 |
631 |
$2K |
| D0272 |
Bitewings - two radiographic images |
227 |
227 |
$2K |
| D1351 |
Sealant - per tooth |
82 |
36 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$900.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
13 |
$700.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$260.00 |