| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,376 |
3,772 |
$755K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,921 |
1,959 |
$341K |
| D1110 |
Prophylaxis - adult |
7,411 |
7,407 |
$307K |
| D2740 |
Crown - porcelain/ceramic |
452 |
268 |
$295K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,446 |
2,000 |
$250K |
| D0120 |
Periodic oral evaluation - established patient |
9,146 |
9,142 |
$221K |
| D0210 |
Intraoral - complete series of radiographic images |
3,166 |
3,067 |
$181K |
| D1120 |
Prophylaxis - child |
3,104 |
3,099 |
$125K |
| D2790 |
|
212 |
170 |
$123K |
| D0220 |
Intraoral - periapical first radiographic image |
8,903 |
8,113 |
$115K |
| D4341 |
|
758 |
322 |
$112K |
| D0140 |
Limited oral evaluation - problem focused |
3,274 |
3,107 |
$107K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,943 |
3,940 |
$96K |
| D0274 |
Bitewings - four radiographic images |
3,325 |
3,323 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,626 |
2,622 |
$92K |
| D2950 |
|
540 |
404 |
$88K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,040 |
5,826 |
$82K |
| D2332 |
|
622 |
418 |
$63K |
| D2722 |
|
93 |
79 |
$56K |
| D1351 |
Sealant - per tooth |
1,251 |
193 |
$40K |
| D4342 |
|
352 |
160 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
494 |
250 |
$30K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
31 |
27 |
$19K |
| D4910 |
|
211 |
211 |
$19K |
| D2394 |
|
165 |
132 |
$19K |
| D2335 |
|
184 |
111 |
$18K |
| D3320 |
|
34 |
28 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
145 |
98 |
$17K |
| D0272 |
Bitewings - two radiographic images |
362 |
362 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
42 |
25 |
$3K |
| D4355 |
|
16 |
16 |
$2K |
| D2330 |
|
44 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$809.92 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$360.00 |
| D1310 |
|
12 |
12 |
$0.00 |
| D0180 |
|
35 |
35 |
$0.00 |
| D1999 |
|
28 |
28 |
$0.00 |