| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,385 |
1,676 |
$254K |
| D1120 |
Prophylaxis - child |
5,221 |
4,877 |
$220K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,475 |
1,439 |
$210K |
| D1206 |
Topical application of fluoride varnish |
3,405 |
3,167 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
5,372 |
4,987 |
$110K |
| D1351 |
Sealant - per tooth |
3,220 |
903 |
$106K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,014 |
701 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,389 |
2,242 |
$66K |
| D1110 |
Prophylaxis - adult |
611 |
549 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,546 |
1,437 |
$37K |
| D1310 |
|
565 |
469 |
$19K |
| D0274 |
Bitewings - four radiographic images |
536 |
485 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
511 |
497 |
$18K |
| D1330 |
|
562 |
467 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
633 |
603 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
25 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
173 |
$6K |
| D0330 |
Panoramic radiographic image |
87 |
77 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
27 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
19 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$171.00 |