| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,375 |
860 |
$275K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,783 |
930 |
$101K |
| D1110 |
Prophylaxis - adult |
2,378 |
2,333 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,615 |
2,562 |
$67K |
| D0330 |
Panoramic radiographic image |
1,343 |
1,339 |
$62K |
| D1120 |
Prophylaxis - child |
2,259 |
2,252 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,909 |
2,903 |
$43K |
| D0274 |
Bitewings - four radiographic images |
2,141 |
2,091 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
2,422 |
2,417 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
1,784 |
1,684 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
4,948 |
4,778 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,204 |
3,795 |
$21K |
| D0272 |
Bitewings - two radiographic images |
993 |
986 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
89 |
44 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
145 |
72 |
$9K |
| D2335 |
|
76 |
37 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
13 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
59 |
$4K |
| D1320 |
|
230 |
207 |
$3K |
| D1351 |
Sealant - per tooth |
57 |
16 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
39 |
$1K |
| D1321 |
|
64 |
48 |
$675.00 |
| D0470 |
|
13 |
13 |
$262.24 |