| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,853 |
2,458 |
$492K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,302 |
1,456 |
$435K |
| D1120 |
Prophylaxis - child |
9,149 |
9,148 |
$397K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,322 |
2,374 |
$320K |
| D0120 |
Periodic oral evaluation - established patient |
8,650 |
8,650 |
$300K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,972 |
9,971 |
$283K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,957 |
1,219 |
$176K |
| D1351 |
Sealant - per tooth |
4,093 |
1,731 |
$135K |
| D0272 |
Bitewings - two radiographic images |
3,650 |
3,650 |
$94K |
| D0140 |
Limited oral evaluation - problem focused |
1,296 |
1,278 |
$81K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
529 |
378 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,055 |
1,054 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
3,172 |
3,131 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,257 |
1,827 |
$57K |
| D1110 |
Prophylaxis - adult |
819 |
819 |
$46K |
| D0240 |
|
1,990 |
1,032 |
$43K |
| D0330 |
Panoramic radiographic image |
260 |
260 |
$20K |
| D0274 |
Bitewings - four radiographic images |
97 |
96 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D2330 |
|
18 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$516.00 |