| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,912 |
3,472 |
$594K |
| D0120 |
Periodic oral evaluation - established patient |
21,777 |
20,663 |
$527K |
| D1110 |
Prophylaxis - adult |
14,271 |
13,502 |
$512K |
| D0140 |
Limited oral evaluation - problem focused |
9,152 |
8,306 |
$310K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,542 |
2,097 |
$256K |
| D1206 |
Topical application of fluoride varnish |
16,173 |
15,427 |
$244K |
| D1120 |
Prophylaxis - child |
8,857 |
8,497 |
$228K |
| D0330 |
Panoramic radiographic image |
4,542 |
4,253 |
$220K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,006 |
1,418 |
$177K |
| D0274 |
Bitewings - four radiographic images |
4,707 |
4,435 |
$145K |
| D0220 |
Intraoral - periapical first radiographic image |
10,199 |
9,079 |
$140K |
| D9420 |
|
1,463 |
1,176 |
$139K |
| D0272 |
Bitewings - two radiographic images |
7,021 |
6,737 |
$124K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,961 |
2,703 |
$110K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,258 |
2,526 |
$95K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
386 |
120 |
$44K |
| D1351 |
Sealant - per tooth |
1,834 |
446 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
334 |
273 |
$42K |
| D2335 |
|
294 |
188 |
$33K |
| D2331 |
|
303 |
181 |
$22K |
| D4355 |
|
346 |
312 |
$19K |
| D9110 |
|
405 |
345 |
$16K |
| D2332 |
|
101 |
64 |
$10K |
| D2330 |
|
153 |
89 |
$8K |
| D2950 |
|
85 |
25 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
59 |
14 |
$2K |
| D5421 |
|
25 |
24 |
$823.32 |
| D5422 |
|
14 |
13 |
$448.09 |