| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,711 |
950 |
$319K |
| D2394 |
|
1,607 |
601 |
$266K |
| D1120 |
Prophylaxis - child |
5,144 |
5,139 |
$203K |
| D2740 |
Crown - porcelain/ceramic |
251 |
124 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
5,454 |
5,437 |
$145K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,007 |
487 |
$141K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,097 |
5,092 |
$119K |
| D1110 |
Prophylaxis - adult |
1,984 |
1,977 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
5,189 |
5,144 |
$83K |
| D0274 |
Bitewings - four radiographic images |
2,411 |
2,403 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,462 |
1,461 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,181 |
4,315 |
$54K |
| D2335 |
|
356 |
144 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
391 |
167 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,400 |
1,399 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
594 |
588 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
260 |
148 |
$21K |
| D0330 |
Panoramic radiographic image |
213 |
213 |
$13K |
| D1206 |
Topical application of fluoride varnish |
434 |
433 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
106 |
29 |
$12K |
| D3240 |
|
87 |
29 |
$10K |
| D2954 |
|
51 |
35 |
$10K |
| D1351 |
Sealant - per tooth |
252 |
68 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
50 |
50 |
$1K |