| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,278 |
1,878 |
$310K |
| D1110 |
Prophylaxis - adult |
5,197 |
5,183 |
$218K |
| D1351 |
Sealant - per tooth |
6,567 |
719 |
$198K |
| D0210 |
Intraoral - complete series of radiographic images |
3,727 |
3,667 |
$185K |
| D0120 |
Periodic oral evaluation - established patient |
5,860 |
5,851 |
$135K |
| D0140 |
Limited oral evaluation - problem focused |
3,893 |
3,831 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,573 |
3,556 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,495 |
911 |
$102K |
| D0274 |
Bitewings - four radiographic images |
3,563 |
3,555 |
$94K |
| D2740 |
Crown - porcelain/ceramic |
135 |
79 |
$91K |
| D0220 |
Intraoral - periapical first radiographic image |
7,105 |
6,975 |
$79K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,036 |
4,650 |
$58K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
491 |
365 |
$57K |
| D2950 |
|
273 |
190 |
$44K |
| D4341 |
|
272 |
84 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,776 |
1,775 |
$41K |
| D1120 |
Prophylaxis - child |
935 |
935 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
979 |
326 |
$34K |
| D4910 |
|
317 |
317 |
$28K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
68 |
35 |
$8K |
| D4346 |
|
91 |
91 |
$6K |
| D0330 |
Panoramic radiographic image |
202 |
200 |
$5K |
| D0270 |
|
223 |
221 |
$3K |
| D4355 |
|
60 |
60 |
$2K |
| D2330 |
|
20 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$807.85 |