| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,888 |
981 |
$233K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
9,503 |
6,301 |
$230K |
| D1120 |
Prophylaxis - child |
9,301 |
6,300 |
$168K |
| D0330 |
Panoramic radiographic image |
3,913 |
2,701 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,710 |
669 |
$108K |
| D1351 |
Sealant - per tooth |
4,184 |
762 |
$89K |
| D1206 |
Topical application of fluoride varnish |
4,904 |
3,583 |
$84K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
880 |
331 |
$84K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,885 |
2,938 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
685 |
276 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
1,218 |
901 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,988 |
1,356 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,782 |
1,969 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
241 |
149 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
1,006 |
372 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
223 |
$6K |
| D1110 |
Prophylaxis - adult |
80 |
69 |
$3K |
| D2330 |
|
37 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
30 |
$309.66 |