| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,343 |
2,372 |
$310K |
| D1120 |
Prophylaxis - child |
5,671 |
5,671 |
$208K |
| D0274 |
Bitewings - four radiographic images |
5,220 |
5,220 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
5,058 |
5,058 |
$125K |
| D1206 |
Topical application of fluoride varnish |
4,088 |
4,083 |
$92K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
893 |
742 |
$78K |
| D1351 |
Sealant - per tooth |
2,057 |
1,050 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
5,411 |
5,408 |
$57K |
| D3240 |
|
276 |
239 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,145 |
825 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
608 |
539 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,316 |
1,006 |
$43K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
514 |
468 |
$34K |
| D1110 |
Prophylaxis - adult |
720 |
720 |
$32K |
| D2331 |
|
424 |
333 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,198 |
5,198 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,500 |
2,500 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,065 |
1,065 |
$24K |
| D1510 |
|
240 |
233 |
$21K |
| D0330 |
Panoramic radiographic image |
578 |
578 |
$17K |
| D9110 |
|
345 |
341 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
243 |
243 |
$5K |
| D2330 |
|
31 |
24 |
$1K |
| D9990 |
|
28 |
26 |
$523.60 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$408.33 |