| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,694 |
796 |
$212K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,051 |
348 |
$161K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,284 |
523 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,834 |
1,778 |
$97K |
| D1110 |
Prophylaxis - adult |
1,250 |
1,220 |
$76K |
| D1120 |
Prophylaxis - child |
1,506 |
1,470 |
$67K |
| D0330 |
Panoramic radiographic image |
1,234 |
1,190 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,733 |
1,700 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,262 |
1,233 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,393 |
1,356 |
$32K |
| D4341 |
|
391 |
162 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
634 |
609 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,949 |
1,863 |
$20K |
| D1351 |
Sealant - per tooth |
484 |
88 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
100 |
15 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,302 |
1,271 |
$10K |
| D0272 |
Bitewings - two radiographic images |
515 |
499 |
$8K |
| D2740 |
Crown - porcelain/ceramic |
19 |
15 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
43 |
$7K |
| D1330 |
|
1,136 |
1,106 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
62 |
29 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
114 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$568.88 |