| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,628 |
777 |
$95K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,394 |
569 |
$76K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,069 |
362 |
$73K |
| D1110 |
Prophylaxis - adult |
1,553 |
1,441 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,058 |
1,906 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,896 |
1,793 |
$46K |
| D1351 |
Sealant - per tooth |
1,735 |
240 |
$40K |
| D0330 |
Panoramic radiographic image |
914 |
876 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
772 |
685 |
$36K |
| D4346 |
|
242 |
206 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,197 |
1,123 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,586 |
1,462 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
568 |
534 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
100 |
63 |
$12K |
| D1120 |
Prophylaxis - child |
309 |
305 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
578 |
520 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
54 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
16 |
$194.65 |
| D1330 |
|
32 |
28 |
$0.00 |
| D3120 |
|
16 |
12 |
$0.00 |
| D1999 |
|
184 |
146 |
$0.00 |