| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,957 |
430 |
$185K |
| D2394 |
|
806 |
191 |
$49K |
| D7311 |
|
637 |
224 |
$42K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
655 |
180 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
573 |
199 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,388 |
806 |
$31K |
| D0330 |
Panoramic radiographic image |
1,475 |
871 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
731 |
95 |
$27K |
| D1110 |
Prophylaxis - adult |
1,246 |
730 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,633 |
999 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,801 |
1,091 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,445 |
843 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,436 |
1,410 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
781 |
487 |
$16K |
| D1206 |
Topical application of fluoride varnish |
2,066 |
1,230 |
$14K |
| D1120 |
Prophylaxis - child |
843 |
512 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
198 |
53 |
$5K |
| D0272 |
Bitewings - two radiographic images |
320 |
195 |
$3K |
| D1351 |
Sealant - per tooth |
254 |
25 |
$3K |
| D4346 |
|
19 |
12 |
$430.13 |
| D0801 |
|
545 |
359 |
$0.00 |
| D1330 |
|
864 |
543 |
$0.00 |
| D0350 |
|
1,169 |
365 |
$0.00 |
| D0431 |
|
202 |
78 |
$0.00 |
| D4921 |
|
141 |
27 |
$0.00 |