| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,310 |
659 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,401 |
766 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
2,845 |
2,714 |
$63K |
| D1120 |
Prophylaxis - child |
2,222 |
2,121 |
$42K |
| D1206 |
Topical application of fluoride varnish |
3,343 |
3,199 |
$41K |
| D1110 |
Prophylaxis - adult |
1,371 |
1,323 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
3,867 |
3,681 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,302 |
1,252 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
728 |
714 |
$26K |
| D0330 |
Panoramic radiographic image |
938 |
913 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,547 |
2,933 |
$24K |
| D0350 |
|
1,541 |
1,419 |
$24K |
| D2394 |
|
244 |
141 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
788 |
742 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
261 |
171 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
163 |
53 |
$11K |
| D0272 |
Bitewings - two radiographic images |
841 |
807 |
$11K |
| D1351 |
Sealant - per tooth |
513 |
133 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
323 |
290 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
43 |
$3K |
| D0250 |
|
98 |
89 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$950.00 |
| D2332 |
|
25 |
12 |
$397.00 |
| D9996 |
|
33 |
33 |
$243.00 |