| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
486 |
304 |
$62K |
| D1120 |
Prophylaxis - child |
1,274 |
1,274 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,521 |
1,521 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
455 |
298 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,465 |
1,465 |
$43K |
| D0272 |
Bitewings - two radiographic images |
770 |
770 |
$21K |
| D1351 |
Sealant - per tooth |
617 |
195 |
$21K |
| D1110 |
Prophylaxis - adult |
354 |
354 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
108 |
86 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
179 |
125 |
$16K |
| D2330 |
|
125 |
69 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
54 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
264 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
62 |
62 |
$3K |
| D0240 |
|
122 |
122 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
65 |
$1K |