| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,125 |
1,433 |
$175K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,815 |
1,482 |
$170K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,380 |
1,496 |
$168K |
| D1110 |
Prophylaxis - adult |
3,498 |
3,370 |
$146K |
| D0330 |
Panoramic radiographic image |
2,427 |
2,335 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
3,458 |
3,338 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,654 |
2,565 |
$75K |
| D1120 |
Prophylaxis - child |
2,250 |
2,172 |
$73K |
| D2394 |
|
779 |
613 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,203 |
3,090 |
$64K |
| D2750 |
|
95 |
74 |
$49K |
| D5110 |
|
69 |
67 |
$47K |
| D9110 |
|
954 |
905 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,626 |
1,564 |
$40K |
| D5120 |
|
44 |
43 |
$30K |
| D1351 |
Sealant - per tooth |
742 |
209 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
160 |
60 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,384 |
1,271 |
$15K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
18 |
15 |
$11K |
| D4342 |
|
240 |
60 |
$7K |
| D3320 |
|
13 |
13 |
$7K |
| D0272 |
Bitewings - two radiographic images |
373 |
354 |
$6K |
| D2330 |
|
51 |
38 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
464 |
381 |
$2K |
| D1206 |
Topical application of fluoride varnish |
15 |
14 |
$287.00 |