| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,166 |
671 |
$69K |
| D1120 |
Prophylaxis - child |
2,418 |
2,412 |
$66K |
| D1206 |
Topical application of fluoride varnish |
3,147 |
3,134 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,724 |
2,715 |
$60K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
433 |
143 |
$42K |
| D1351 |
Sealant - per tooth |
1,321 |
291 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
519 |
272 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
525 |
360 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,209 |
1,208 |
$23K |
| D1110 |
Prophylaxis - adult |
585 |
584 |
$21K |
| D0603 |
|
1,610 |
1,606 |
$16K |
| D0274 |
Bitewings - four radiographic images |
458 |
457 |
$14K |
| D1330 |
|
1,992 |
1,988 |
$12K |
| D0330 |
Panoramic radiographic image |
269 |
268 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
400 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
147 |
65 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
73 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
103 |
$5K |
| D1310 |
|
290 |
282 |
$4K |
| D0240 |
|
239 |
174 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
295 |
294 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
72 |
$585.27 |
| D0602 |
|
48 |
48 |
$480.00 |