| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,506 |
833 |
$138K |
| D1110 |
Prophylaxis - adult |
3,527 |
3,134 |
$137K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,175 |
679 |
$85K |
| D0330 |
Panoramic radiographic image |
2,408 |
2,148 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,843 |
3,589 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,532 |
2,351 |
$83K |
| D1120 |
Prophylaxis - child |
1,592 |
1,564 |
$67K |
| D2750 |
|
136 |
96 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,405 |
2,347 |
$57K |
| D0274 |
Bitewings - four radiographic images |
3,220 |
2,930 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
641 |
303 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,562 |
1,394 |
$36K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
36 |
32 |
$27K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
326 |
161 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,382 |
2,078 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
655 |
461 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
49 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,120 |
795 |
$7K |
| D4341 |
|
63 |
26 |
$5K |
| D2950 |
|
56 |
46 |
$5K |
| D1351 |
Sealant - per tooth |
138 |
15 |
$5K |
| D0272 |
Bitewings - two radiographic images |
181 |
166 |
$2K |
| D1330 |
|
277 |
271 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$368.00 |
| D1999 |
|
22 |
14 |
$0.00 |