| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,358 |
1,050 |
$143K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,077 |
313 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,521 |
2,313 |
$90K |
| D4341 |
|
1,747 |
377 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,128 |
603 |
$69K |
| D1351 |
Sealant - per tooth |
5,113 |
1,077 |
$57K |
| D1330 |
|
2,843 |
2,604 |
$47K |
| D4342 |
|
1,900 |
516 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,144 |
364 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,468 |
2,331 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
2,229 |
2,032 |
$39K |
| D1110 |
Prophylaxis - adult |
1,535 |
1,424 |
$36K |
| D2740 |
Crown - porcelain/ceramic |
140 |
102 |
$34K |
| D5213 |
|
28 |
28 |
$12K |
| D2332 |
|
112 |
65 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
454 |
447 |
$8K |
| D5214 |
|
12 |
12 |
$7K |
| D5110 |
|
15 |
14 |
$7K |
| D2950 |
|
107 |
78 |
$5K |
| D0274 |
Bitewings - four radiographic images |
546 |
539 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
793 |
758 |
$2K |
| D0601 |
|
167 |
165 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
160 |
158 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
526 |
514 |
$958.01 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$901.00 |
| D1120 |
Prophylaxis - child |
40 |
40 |
$545.64 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
253 |
148 |
$0.00 |