| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,956 |
932 |
$256K |
| D3120 |
|
3,651 |
1,218 |
$125K |
| D2750 |
|
206 |
118 |
$100K |
| D1110 |
Prophylaxis - adult |
1,582 |
1,528 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
888 |
473 |
$92K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
104 |
83 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,284 |
2,202 |
$69K |
| D1206 |
Topical application of fluoride varnish |
2,759 |
2,669 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,092 |
1,063 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
345 |
224 |
$57K |
| D1120 |
Prophylaxis - child |
1,097 |
1,065 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
744 |
730 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,669 |
1,595 |
$38K |
| D8670 |
Periodic orthodontic treatment visit |
502 |
478 |
$37K |
| D4341 |
|
230 |
61 |
$21K |
| D3320 |
|
14 |
12 |
$9K |
| D2952 |
|
73 |
48 |
$7K |
| D1351 |
Sealant - per tooth |
187 |
31 |
$7K |
| D0272 |
Bitewings - two radiographic images |
392 |
379 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
318 |
$4K |
| D1330 |
|
568 |
537 |
$3K |
| D0330 |
Panoramic radiographic image |
73 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
38 |
$2K |
| D2950 |
|
15 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$137.76 |