| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,212 |
1,431 |
$298K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,715 |
1,041 |
$180K |
| D1110 |
Prophylaxis - adult |
2,984 |
2,973 |
$126K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,168 |
467 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,022 |
2,007 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,845 |
2,829 |
$65K |
| D1206 |
Topical application of fluoride varnish |
3,195 |
3,163 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,538 |
1,527 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
1,205 |
1,172 |
$40K |
| D1120 |
Prophylaxis - child |
817 |
805 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
310 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,647 |
1,614 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
81 |
$18K |
| D0330 |
Panoramic radiographic image |
155 |
155 |
$8K |
| D2331 |
|
52 |
37 |
$6K |
| D9110 |
|
90 |
89 |
$5K |
| D4910 |
|
69 |
69 |
$4K |
| D0272 |
Bitewings - two radiographic images |
155 |
151 |
$3K |
| D2330 |
|
33 |
26 |
$3K |
| D1351 |
Sealant - per tooth |
61 |
22 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
93 |
$2K |
| D0190 |
|
12 |
12 |
$204.24 |