| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,862 |
679 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,528 |
410 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
2,611 |
2,418 |
$4K |
| D1120 |
Prophylaxis - child |
1,062 |
998 |
$4K |
| D1110 |
Prophylaxis - adult |
1,610 |
1,470 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,940 |
2,707 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,577 |
1,453 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
1,064 |
991 |
$2K |
| D0272 |
Bitewings - two radiographic images |
897 |
864 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,569 |
1,489 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,532 |
1,219 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
368 |
308 |
$1K |
| D9420 |
|
435 |
366 |
$962.76 |
| D2330 |
|
187 |
52 |
$869.75 |
| D9243 |
|
467 |
170 |
$480.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
117 |
39 |
$280.14 |
| D9239 |
|
164 |
147 |
$131.00 |
| D4341 |
|
554 |
159 |
$104.71 |
| D1351 |
Sealant - per tooth |
58 |
13 |
$82.40 |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
61 |
$48.61 |
| D1999 |
|
138 |
132 |
$8.80 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
13 |
$0.00 |
| D0350 |
|
19 |
19 |
$0.00 |