| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
986 |
540 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
790 |
382 |
$42K |
| D1110 |
Prophylaxis - adult |
830 |
796 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,615 |
1,539 |
$25K |
| D1120 |
Prophylaxis - child |
962 |
934 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,289 |
1,249 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
313 |
183 |
$15K |
| D0330 |
Panoramic radiographic image |
206 |
198 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
306 |
296 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
50 |
$4K |
| D0272 |
Bitewings - two radiographic images |
488 |
468 |
$4K |
| D0274 |
Bitewings - four radiographic images |
257 |
246 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
182 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
141 |
40 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
32 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
328 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
278 |
66 |
$1K |
| D2330 |
|
27 |
12 |
$1K |