| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,048 |
728 |
$145K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,225 |
802 |
$130K |
| D1110 |
Prophylaxis - adult |
1,663 |
1,607 |
$97K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,160 |
508 |
$95K |
| D0274 |
Bitewings - four radiographic images |
1,962 |
1,917 |
$82K |
| D0330 |
Panoramic radiographic image |
887 |
855 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
1,597 |
1,532 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,785 |
1,170 |
$51K |
| D1351 |
Sealant - per tooth |
1,295 |
393 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,678 |
1,621 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
760 |
737 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
1,499 |
1,465 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
159 |
135 |
$29K |
| D1120 |
Prophylaxis - child |
539 |
520 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
293 |
283 |
$15K |
| D2950 |
|
29 |
27 |
$6K |
| D2330 |
|
54 |
39 |
$5K |
| D0272 |
Bitewings - two radiographic images |
147 |
143 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$3K |
| D2331 |
|
33 |
28 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
56 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$486.00 |