| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,028 |
1,626 |
$309K |
| D8670 |
Periodic orthodontic treatment visit |
2,091 |
1,831 |
$229K |
| D0120 |
Periodic oral evaluation - established patient |
5,490 |
5,311 |
$157K |
| D2740 |
Crown - porcelain/ceramic |
265 |
179 |
$107K |
| D1120 |
Prophylaxis - child |
4,395 |
4,253 |
$103K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
272 |
209 |
$95K |
| D1351 |
Sealant - per tooth |
4,260 |
1,177 |
$91K |
| D1206 |
Topical application of fluoride varnish |
6,402 |
6,191 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,368 |
789 |
$80K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
831 |
461 |
$79K |
| D1110 |
Prophylaxis - adult |
2,205 |
2,134 |
$70K |
| D0272 |
Bitewings - two radiographic images |
4,207 |
4,067 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,287 |
1,247 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,176 |
2,105 |
$54K |
| D2950 |
|
384 |
253 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
532 |
316 |
$28K |
| D0330 |
Panoramic radiographic image |
628 |
597 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
757 |
726 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
25 |
$3K |
| D2330 |
|
49 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
83 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$563.00 |