| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,385 |
5,703 |
$288K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,188 |
1,452 |
$278K |
| D0120 |
Periodic oral evaluation - established patient |
8,703 |
8,070 |
$230K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
378 |
282 |
$201K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,916 |
4,027 |
$201K |
| D1120 |
Prophylaxis - child |
4,528 |
4,489 |
$160K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,569 |
760 |
$159K |
| D0330 |
Panoramic radiographic image |
3,249 |
2,484 |
$144K |
| D2931 |
|
460 |
312 |
$128K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,003 |
5,958 |
$122K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,862 |
801 |
$121K |
| D2950 |
|
663 |
452 |
$96K |
| D0272 |
Bitewings - two radiographic images |
4,201 |
4,152 |
$90K |
| D0274 |
Bitewings - four radiographic images |
2,497 |
2,047 |
$71K |
| D1351 |
Sealant - per tooth |
1,882 |
682 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
767 |
329 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
1,140 |
991 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
76 |
52 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
14 |
$6K |
| D9920 |
|
62 |
58 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
52 |
52 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
118 |
$2K |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$364.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
12 |
$285.77 |