| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,852 |
825 |
$252K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,326 |
544 |
$228K |
| D1110 |
Prophylaxis - adult |
1,952 |
1,939 |
$126K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,064 |
522 |
$113K |
| D0140 |
Limited oral evaluation - problem focused |
1,389 |
1,294 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,123 |
1,109 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,164 |
2,147 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
886 |
874 |
$50K |
| D3120 |
|
1,412 |
408 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,212 |
1,201 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
896 |
895 |
$28K |
| D2332 |
|
177 |
75 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,278 |
2,127 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
52 |
42 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,617 |
1,595 |
$12K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
14 |
$10K |
| D2394 |
|
44 |
29 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
33 |
$7K |
| D2950 |
|
71 |
58 |
$6K |
| D4341 |
|
32 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
72 |
13 |
$3K |
| D1330 |
|
344 |
340 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$597.35 |