| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,510 |
2,943 |
$378K |
| D1110 |
Prophylaxis - adult |
6,429 |
6,248 |
$306K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
3,365 |
1,857 |
$262K |
| D0330 |
Panoramic radiographic image |
5,172 |
5,047 |
$247K |
| D1351 |
Sealant - per tooth |
7,461 |
1,139 |
$217K |
| D0274 |
Bitewings - four radiographic images |
6,885 |
6,697 |
$185K |
| D1120 |
Prophylaxis - child |
3,014 |
2,961 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
6,663 |
6,487 |
$162K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,969 |
4,848 |
$149K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
232 |
214 |
$128K |
| D2394 |
|
1,083 |
764 |
$90K |
| D1206 |
Topical application of fluoride varnish |
4,162 |
4,080 |
$83K |
| D2740 |
Crown - porcelain/ceramic |
160 |
122 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,765 |
3,611 |
$77K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,114 |
495 |
$74K |
| D0220 |
Intraoral - periapical first radiographic image |
6,546 |
6,153 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
1,199 |
1,157 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,299 |
2,239 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
337 |
245 |
$19K |
| D4341 |
|
237 |
83 |
$15K |
| D0272 |
Bitewings - two radiographic images |
464 |
458 |
$8K |
| D2950 |
|
14 |
12 |
$2K |
| D2940 |
|
39 |
31 |
$507.51 |
| D0431 |
|
17 |
17 |
$160.00 |
| D9986 |
|
88 |
74 |
$0.00 |