| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,306 |
1,676 |
$220K |
| D0350 |
|
19,580 |
4,939 |
$175K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,549 |
2,547 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
2,263 |
2,250 |
$157K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,904 |
1,495 |
$157K |
| D0340 |
|
2,720 |
2,717 |
$133K |
| D8670 |
Periodic orthodontic treatment visit |
436 |
433 |
$130K |
| D1120 |
Prophylaxis - child |
2,793 |
2,782 |
$127K |
| D1110 |
Prophylaxis - adult |
1,287 |
1,286 |
$114K |
| D0210 |
Intraoral - complete series of radiographic images |
2,303 |
2,301 |
$109K |
| D1351 |
Sealant - per tooth |
3,371 |
830 |
$108K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
216 |
162 |
$103K |
| D4910 |
|
1,151 |
1,143 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,242 |
3,632 |
$76K |
| D4341 |
|
1,051 |
291 |
$73K |
| D2740 |
Crown - porcelain/ceramic |
152 |
103 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,486 |
4,472 |
$61K |
| D0330 |
Panoramic radiographic image |
1,948 |
1,947 |
$57K |
| D9430 |
|
1,622 |
1,449 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,176 |
2,161 |
$45K |
| D1320 |
|
2,872 |
2,865 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
439 |
276 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
529 |
527 |
$18K |
| D7240 |
Removal of impacted tooth - completely bony |
58 |
25 |
$13K |
| D2954 |
|
108 |
85 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
36 |
24 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
26 |
$3K |
| D4342 |
|
64 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
155 |
$2K |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$596.00 |
| D1310 |
|
12 |
12 |
$552.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$312.00 |