| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
11,680 |
9,022 |
$1.07M |
| D1120 |
Prophylaxis - child |
15,034 |
15,034 |
$645K |
| D1110 |
Prophylaxis - adult |
9,526 |
9,526 |
$520K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,378 |
2,746 |
$430K |
| D0120 |
Periodic oral evaluation - established patient |
15,220 |
15,220 |
$415K |
| D1206 |
Topical application of fluoride varnish |
13,220 |
13,220 |
$396K |
| D0274 |
Bitewings - four radiographic images |
13,010 |
13,010 |
$354K |
| D0220 |
Intraoral - periapical first radiographic image |
25,373 |
25,189 |
$335K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
9,465 |
9,465 |
$283K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,683 |
2,231 |
$265K |
| D2740 |
Crown - porcelain/ceramic |
468 |
423 |
$236K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,803 |
3,335 |
$226K |
| D0210 |
Intraoral - complete series of radiographic images |
6,324 |
6,241 |
$195K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,787 |
22,772 |
$193K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
357 |
350 |
$143K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,173 |
1,916 |
$119K |
| D1351 |
Sealant - per tooth |
1,846 |
1,293 |
$110K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
941 |
842 |
$88K |
| D2954 |
|
526 |
487 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,245 |
4,245 |
$59K |
| D1320 |
|
7,163 |
7,163 |
$54K |
| D2331 |
|
514 |
452 |
$51K |
| D0272 |
Bitewings - two radiographic images |
1,810 |
1,808 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
1,952 |
1,907 |
$27K |
| D2394 |
|
184 |
149 |
$26K |
| D3320 |
|
57 |
54 |
$17K |
| D0273 |
|
327 |
327 |
$7K |
| D0330 |
Panoramic radiographic image |
200 |
200 |
$6K |
| D9110 |
|
245 |
241 |
$6K |
| D0270 |
|
332 |
328 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
17 |
16 |
$2K |
| D9310 |
|
15 |
15 |
$1K |
| D1354 |
|
22 |
16 |
$660.00 |
| D1330 |
|
18 |
18 |
$0.00 |
| D1310 |
|
18 |
18 |
$0.00 |