| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
6,372 |
3,191 |
$515K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,168 |
2,686 |
$464K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
9,777 |
2,318 |
$406K |
| D7250 |
|
3,895 |
953 |
$242K |
| D0274 |
Bitewings - four radiographic images |
7,232 |
6,448 |
$200K |
| D1110 |
Prophylaxis - adult |
6,490 |
5,803 |
$200K |
| D2335 |
|
1,831 |
879 |
$191K |
| D0120 |
Periodic oral evaluation - established patient |
8,137 |
7,349 |
$175K |
| D0140 |
Limited oral evaluation - problem focused |
5,915 |
5,178 |
$152K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,000 |
7,280 |
$152K |
| D1120 |
Prophylaxis - child |
3,605 |
3,289 |
$144K |
| D2332 |
|
1,734 |
861 |
$141K |
| D2394 |
|
1,027 |
682 |
$108K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,952 |
660 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,609 |
4,858 |
$101K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,627 |
794 |
$99K |
| D0220 |
Intraoral - periapical first radiographic image |
9,132 |
7,916 |
$96K |
| D0210 |
Intraoral - complete series of radiographic images |
1,966 |
1,695 |
$94K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
196 |
150 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,509 |
1,317 |
$56K |
| D2160 |
|
471 |
292 |
$31K |
| D2791 |
|
86 |
72 |
$31K |
| D2330 |
|
453 |
208 |
$23K |
| D2950 |
|
454 |
252 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
322 |
143 |
$12K |
| D1206 |
Topical application of fluoride varnish |
557 |
531 |
$10K |
| D2331 |
|
110 |
69 |
$8K |
| D2161 |
|
48 |
40 |
$5K |
| D0272 |
Bitewings - two radiographic images |
141 |
120 |
$3K |
| D9310 |
|
99 |
94 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
14 |
$646.80 |
| D2140 |
|
57 |
13 |
$588.12 |