| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
6,472 |
1,278 |
$326K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,981 |
1,146 |
$314K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,684 |
474 |
$117K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
930 |
308 |
$67K |
| D1120 |
Prophylaxis - child |
2,316 |
2,127 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,869 |
2,636 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,641 |
1,493 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,613 |
1,490 |
$29K |
| D1110 |
Prophylaxis - adult |
889 |
821 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
268 |
150 |
$14K |
| D0272 |
Bitewings - two radiographic images |
849 |
781 |
$12K |
| D2330 |
|
220 |
77 |
$11K |
| D1351 |
Sealant - per tooth |
408 |
140 |
$8K |
| D0274 |
Bitewings - four radiographic images |
397 |
370 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
242 |
217 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
185 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
48 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
77 |
$966.48 |
| D0350 |
|
1,109 |
1,024 |
$9.65 |
| D1310 |
|
674 |
652 |
$0.00 |
| D1330 |
|
817 |
792 |
$0.00 |
| D9630 |
|
85 |
71 |
$0.00 |
| D9911 |
|
52 |
12 |
$0.00 |
| D0351 |
|
33 |
30 |
$0.00 |