| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4212 |
|
994 |
385 |
$155K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,226 |
617 |
$64K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
595 |
296 |
$60K |
| D1110 |
Prophylaxis - adult |
1,674 |
1,572 |
$44K |
| D2335 |
|
385 |
175 |
$42K |
| D2394 |
|
543 |
352 |
$33K |
| D0330 |
Panoramic radiographic image |
811 |
760 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
2,292 |
2,161 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,088 |
1,027 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
973 |
925 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
372 |
276 |
$17K |
| D4346 |
|
302 |
276 |
$16K |
| D1120 |
Prophylaxis - child |
899 |
831 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,282 |
1,181 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
484 |
455 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
98 |
$4K |
| D1351 |
Sealant - per tooth |
181 |
38 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
454 |
415 |
$3K |
| D0272 |
Bitewings - two radiographic images |
78 |
70 |
$1K |
| D1206 |
Topical application of fluoride varnish |
58 |
56 |
$1K |
| D0170 |
|
13 |
12 |
$120.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
41 |
$80.00 |