| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,798 |
876 |
$238K |
| D2750 |
|
467 |
286 |
$211K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,066 |
3,003 |
$165K |
| D1110 |
Prophylaxis - adult |
2,268 |
2,219 |
$144K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
815 |
461 |
$135K |
| D1206 |
Topical application of fluoride varnish |
5,250 |
5,091 |
$130K |
| D1120 |
Prophylaxis - child |
2,858 |
2,769 |
$124K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
158 |
130 |
$114K |
| D2740 |
Crown - porcelain/ceramic |
279 |
172 |
$108K |
| D0330 |
Panoramic radiographic image |
2,336 |
2,293 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
2,949 |
2,863 |
$88K |
| D0220 |
Intraoral - periapical first radiographic image |
7,555 |
6,427 |
$80K |
| D2950 |
|
892 |
582 |
$75K |
| D0274 |
Bitewings - four radiographic images |
2,884 |
2,829 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
577 |
261 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
1,102 |
1,065 |
$51K |
| D3320 |
|
67 |
56 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
266 |
103 |
$31K |
| D1351 |
Sealant - per tooth |
968 |
119 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,344 |
4,228 |
$29K |
| D4341 |
|
188 |
66 |
$15K |
| D1330 |
|
2,260 |
2,173 |
$14K |
| D0272 |
Bitewings - two radiographic images |
756 |
734 |
$12K |
| D4355 |
|
98 |
95 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$684.00 |
| D0460 |
|
31 |
27 |
$310.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
12 |
$276.00 |