| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,301 |
1,544 |
$275K |
| D1110 |
Prophylaxis - adult |
4,037 |
4,031 |
$210K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,017 |
1,349 |
$198K |
| D2720 |
|
197 |
126 |
$173K |
| D0120 |
Periodic oral evaluation - established patient |
5,225 |
5,219 |
$169K |
| D8670 |
Periodic orthodontic treatment visit |
713 |
713 |
$146K |
| D0330 |
Panoramic radiographic image |
1,766 |
1,764 |
$141K |
| D1120 |
Prophylaxis - child |
3,614 |
3,610 |
$128K |
| D1206 |
Topical application of fluoride varnish |
4,233 |
4,228 |
$114K |
| D0274 |
Bitewings - four radiographic images |
2,878 |
2,873 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,096 |
2,095 |
$82K |
| D0220 |
Intraoral - periapical first radiographic image |
5,010 |
4,898 |
$77K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
766 |
347 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,049 |
3,791 |
$57K |
| D2140 |
|
623 |
283 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,101 |
1,089 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
422 |
280 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,003 |
1,001 |
$32K |
| D2950 |
|
173 |
121 |
$28K |
| D0180 |
|
291 |
291 |
$25K |
| D0240 |
|
724 |
364 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
196 |
127 |
$21K |
| D1330 |
|
1,916 |
1,906 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
518 |
516 |
$13K |
| D4341 |
|
31 |
12 |
$6K |
| D2330 |
|
74 |
42 |
$5K |
| D2331 |
|
49 |
28 |
$5K |
| D2160 |
|
37 |
25 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
38 |
12 |
$1K |
| D4910 |
|
13 |
13 |
$233.19 |
| D9985 |
|
14 |
14 |
$55.28 |