| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
10,129 |
4,768 |
$910K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
11,565 |
5,412 |
$854K |
| D1120 |
Prophylaxis - child |
13,713 |
13,689 |
$548K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
8,290 |
8,281 |
$366K |
| D1206 |
Topical application of fluoride varnish |
17,505 |
17,487 |
$363K |
| D0240 |
|
11,338 |
11,324 |
$336K |
| D0120 |
Periodic oral evaluation - established patient |
9,068 |
9,059 |
$250K |
| D0274 |
Bitewings - four radiographic images |
7,222 |
7,211 |
$234K |
| D1351 |
Sealant - per tooth |
8,511 |
2,855 |
$226K |
| D1352 |
|
5,880 |
1,630 |
$209K |
| D0272 |
Bitewings - two radiographic images |
9,382 |
9,374 |
$208K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,396 |
490 |
$172K |
| D1999 |
|
14,222 |
11,628 |
$165K |
| D1110 |
Prophylaxis - adult |
3,152 |
3,147 |
$158K |
| D2330 |
|
1,563 |
741 |
$118K |
| D0330 |
Panoramic radiographic image |
1,938 |
1,934 |
$109K |
| D4355 |
|
1,345 |
1,331 |
$99K |
| D0220 |
Intraoral - periapical first radiographic image |
5,750 |
5,729 |
$76K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
631 |
434 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,711 |
5,642 |
$62K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
538 |
229 |
$42K |
| D3120 |
|
1,319 |
618 |
$36K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
379 |
218 |
$30K |
| D4341 |
|
110 |
87 |
$27K |
| D2332 |
|
159 |
99 |
$18K |
| D2331 |
|
184 |
124 |
$17K |
| D2140 |
|
263 |
173 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
163 |
81 |
$12K |
| D2335 |
|
49 |
30 |
$7K |
| D2940 |
|
46 |
32 |
$2K |