| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,416 |
3,301 |
$399K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,846 |
2,340 |
$226K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,974 |
1,346 |
$172K |
| D1110 |
Prophylaxis - adult |
4,136 |
3,778 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
5,771 |
5,389 |
$102K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,426 |
6,804 |
$100K |
| D1120 |
Prophylaxis - child |
3,751 |
3,486 |
$99K |
| D0330 |
Panoramic radiographic image |
2,400 |
2,127 |
$93K |
| D1999 |
|
3,875 |
3,294 |
$68K |
| D0274 |
Bitewings - four radiographic images |
2,545 |
2,262 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,288 |
2,020 |
$51K |
| D0272 |
Bitewings - two radiographic images |
1,926 |
1,780 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
594 |
524 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
50 |
24 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
110 |
82 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
111 |
84 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
875 |
686 |
$8K |
| D2332 |
|
75 |
49 |
$6K |
| D2950 |
|
97 |
52 |
$6K |
| D3310 |
|
16 |
12 |
$5K |
| D2394 |
|
43 |
40 |
$5K |
| D2331 |
|
64 |
37 |
$4K |
| D2335 |
|
31 |
24 |
$3K |
| D2330 |
|
42 |
27 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
57 |
$630.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
176 |
117 |
$0.00 |