| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,380 |
1,773 |
$398K |
| D1120 |
Prophylaxis - child |
8,820 |
8,811 |
$366K |
| D0120 |
Periodic oral evaluation - established patient |
8,560 |
8,552 |
$286K |
| D1206 |
Topical application of fluoride varnish |
8,166 |
8,155 |
$227K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,130 |
1,136 |
$189K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
984 |
697 |
$139K |
| D1351 |
Sealant - per tooth |
2,628 |
817 |
$83K |
| D0272 |
Bitewings - two radiographic images |
2,954 |
2,950 |
$76K |
| D0210 |
Intraoral - complete series of radiographic images |
617 |
617 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
839 |
836 |
$51K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
253 |
146 |
$49K |
| D1110 |
Prophylaxis - adult |
961 |
960 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
2,177 |
2,169 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,256 |
1,253 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
392 |
240 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,051 |
1,176 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
349 |
347 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
506 |
505 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
152 |
101 |
$18K |
| D0274 |
Bitewings - four radiographic images |
369 |
368 |
$15K |
| D1354 |
|
162 |
52 |
$4K |
| D9420 |
|
27 |
27 |
$3K |
| D3120 |
|
28 |
14 |
$0.00 |
| D2941 |
|
22 |
12 |
$0.00 |