| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,085 |
663 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,364 |
739 |
$136K |
| D1120 |
Prophylaxis - child |
2,233 |
2,233 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,399 |
2,399 |
$86K |
| D1206 |
Topical application of fluoride varnish |
2,403 |
2,403 |
$72K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
274 |
212 |
$55K |
| D1110 |
Prophylaxis - adult |
632 |
632 |
$36K |
| D0272 |
Bitewings - two radiographic images |
994 |
994 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
286 |
286 |
$25K |
| D1351 |
Sealant - per tooth |
737 |
274 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
246 |
173 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
99 |
82 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
614 |
602 |
$12K |
| D0240 |
|
417 |
271 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
516 |
294 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
71 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
107 |
107 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$5K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
101 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$3K |
| D2330 |
|
19 |
13 |
$2K |