| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,681 |
1,298 |
$373K |
| D0140 |
Limited oral evaluation - problem focused |
7,106 |
5,572 |
$214K |
| D1120 |
Prophylaxis - child |
8,411 |
6,991 |
$190K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,775 |
233 |
$176K |
| D1206 |
Topical application of fluoride varnish |
5,604 |
4,898 |
$110K |
| D0330 |
Panoramic radiographic image |
2,876 |
2,379 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,473 |
400 |
$83K |
| D8670 |
Periodic orthodontic treatment visit |
807 |
629 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,625 |
2,186 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
8,751 |
6,822 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,510 |
5,730 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,057 |
1,839 |
$51K |
| D0272 |
Bitewings - two radiographic images |
3,683 |
2,994 |
$48K |
| D0274 |
Bitewings - four radiographic images |
2,129 |
1,728 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
307 |
108 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,033 |
1,609 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
446 |
118 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
271 |
195 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
36 |
$6K |
| D1351 |
Sealant - per tooth |
66 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
17 |
13 |
$370.10 |