| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,031 |
1,568 |
$237K |
| D1110 |
Prophylaxis - adult |
4,923 |
4,923 |
$181K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,775 |
1,511 |
$156K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,237 |
877 |
$129K |
| D2394 |
|
1,145 |
553 |
$119K |
| D2750 |
|
304 |
187 |
$118K |
| D0274 |
Bitewings - four radiographic images |
5,242 |
5,242 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
4,937 |
4,937 |
$101K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,270 |
975 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
5,983 |
5,982 |
$58K |
| D1120 |
Prophylaxis - child |
1,062 |
1,062 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,858 |
5,858 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,042 |
1,042 |
$21K |
| D1351 |
Sealant - per tooth |
238 |
160 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,527 |
1,527 |
$17K |
| D2335 |
|
180 |
106 |
$16K |
| D2954 |
|
144 |
103 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
2,219 |
2,219 |
$12K |
| D9310 |
|
186 |
186 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
99 |
83 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
375 |
370 |
$4K |
| D0272 |
Bitewings - two radiographic images |
259 |
259 |
$3K |
| D3320 |
|
15 |
13 |
$3K |
| D9944 |
|
30 |
30 |
$3K |
| D4341 |
|
59 |
25 |
$3K |
| D2330 |
|
53 |
42 |
$2K |
| D2332 |
|
27 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$1K |
| D9430 |
|
49 |
48 |
$591.26 |
| D9110 |
|
13 |
13 |
$239.38 |