| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,857 |
5,090 |
$489K |
| D1120 |
Prophylaxis - child |
12,854 |
12,849 |
$433K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,955 |
3,557 |
$385K |
| D0120 |
Periodic oral evaluation - established patient |
11,357 |
11,354 |
$260K |
| D1206 |
Topical application of fluoride varnish |
10,131 |
10,130 |
$231K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,972 |
2,714 |
$209K |
| D0272 |
Bitewings - two radiographic images |
11,193 |
11,190 |
$133K |
| D1351 |
Sealant - per tooth |
1,429 |
1,186 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,802 |
1,684 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,873 |
2,873 |
$60K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,308 |
1,236 |
$50K |
| D1110 |
Prophylaxis - adult |
1,250 |
1,250 |
$50K |
| D3240 |
|
304 |
298 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
3,560 |
3,518 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
3,187 |
3,113 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
500 |
477 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,894 |
2,893 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,117 |
1,117 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,298 |
1,298 |
$16K |
| D1320 |
|
2,083 |
2,082 |
$12K |
| D9310 |
|
55 |
55 |
$3K |
| D2335 |
|
12 |
12 |
$1K |
| D9920 |
|
17 |
17 |
$304.50 |
| D0270 |
|
12 |
12 |
$116.46 |
| D0240 |
|
1,357 |
1,357 |
$0.00 |
| D9440 |
|
18 |
18 |
$0.00 |