| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
447 |
187 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
322 |
$21K |
| D1120 |
Prophylaxis - child |
410 |
410 |
$20K |
| D1351 |
Sealant - per tooth |
466 |
127 |
$17K |
| D1310 |
|
311 |
311 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
176 |
94 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,812 |
365 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
72 |
38 |
$7K |
| D1206 |
Topical application of fluoride varnish |
214 |
214 |
$7K |
| D0350 |
|
664 |
268 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
98 |
98 |
$6K |
| D0603 |
|
306 |
306 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
31 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
273 |
263 |
$3K |
| D7111 |
|
53 |
27 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
162 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$1K |
| D1320 |
|
76 |
76 |
$797.50 |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$768.00 |