| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,276 |
1,453 |
$258K |
| D1120 |
Prophylaxis - child |
4,494 |
4,494 |
$167K |
| D1110 |
Prophylaxis - adult |
3,212 |
3,202 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
5,294 |
5,288 |
$133K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,398 |
950 |
$125K |
| D1206 |
Topical application of fluoride varnish |
4,811 |
4,808 |
$111K |
| D2740 |
Crown - porcelain/ceramic |
182 |
143 |
$106K |
| D1351 |
Sealant - per tooth |
3,262 |
571 |
$94K |
| D0210 |
Intraoral - complete series of radiographic images |
1,299 |
1,289 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,927 |
1,926 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,033 |
2,026 |
$60K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
338 |
262 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
2,335 |
2,305 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
783 |
772 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
272 |
143 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,013 |
1,013 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,995 |
1,568 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
656 |
656 |
$13K |
| D2950 |
|
84 |
74 |
$12K |
| D0330 |
Panoramic radiographic image |
198 |
197 |
$10K |
| D2331 |
|
47 |
25 |
$5K |
| D0603 |
|
190 |
190 |
$0.00 |
| D0602 |
|
176 |
176 |
$0.00 |
| D0601 |
|
237 |
237 |
$0.00 |