| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,235 |
2,017 |
$281K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,073 |
1,144 |
$174K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,136 |
919 |
$160K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,513 |
461 |
$157K |
| D0120 |
Periodic oral evaluation - established patient |
6,748 |
6,704 |
$117K |
| D1110 |
Prophylaxis - adult |
3,283 |
3,265 |
$111K |
| D1120 |
Prophylaxis - child |
5,336 |
5,296 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,006 |
3,966 |
$106K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,426 |
745 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,840 |
5,783 |
$88K |
| D0330 |
Panoramic radiographic image |
1,705 |
1,697 |
$72K |
| D2335 |
|
658 |
215 |
$62K |
| D0274 |
Bitewings - four radiographic images |
2,597 |
2,581 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
1,710 |
1,677 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
628 |
617 |
$36K |
| D2330 |
|
719 |
240 |
$36K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
442 |
161 |
$28K |
| D2740 |
Crown - porcelain/ceramic |
82 |
42 |
$25K |
| D1351 |
Sealant - per tooth |
654 |
188 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,270 |
1,267 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
217 |
97 |
$12K |
| D2332 |
|
155 |
67 |
$11K |
| D2394 |
|
147 |
105 |
$11K |
| D1206 |
Topical application of fluoride varnish |
572 |
566 |
$11K |
| D2160 |
|
69 |
36 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
923 |
911 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
58 |
28 |
$3K |
| D2140 |
|
83 |
43 |
$3K |
| D2950 |
|
45 |
27 |
$3K |
| D2161 |
|
14 |
12 |
$1K |
| D0240 |
|
56 |
29 |
$672.00 |