| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,682 |
827 |
$217K |
| D1120 |
Prophylaxis - child |
2,564 |
2,557 |
$103K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
918 |
518 |
$90K |
| D1206 |
Topical application of fluoride varnish |
2,652 |
2,645 |
$67K |
| D1354 |
|
2,381 |
797 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
636 |
299 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,752 |
1,748 |
$47K |
| D9310 |
|
609 |
609 |
$34K |
| D1351 |
Sealant - per tooth |
834 |
288 |
$23K |
| D9248 |
|
270 |
250 |
$21K |
| D1110 |
Prophylaxis - adult |
501 |
499 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
112 |
70 |
$20K |
| D2330 |
|
238 |
127 |
$19K |
| D3240 |
|
110 |
70 |
$15K |
| D0330 |
Panoramic radiographic image |
206 |
204 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
338 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
28 |
$4K |
| D2331 |
|
24 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
101 |
100 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
153 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$2K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
28 |
$615.60 |