| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
168 |
112 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
355 |
293 |
$28K |
| D1120 |
Prophylaxis - child |
504 |
487 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
368 |
293 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
655 |
636 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
466 |
448 |
$12K |
| D1351 |
Sealant - per tooth |
128 |
81 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
412 |
395 |
$10K |
| D1110 |
Prophylaxis - adult |
180 |
180 |
$8K |
| D0274 |
Bitewings - four radiographic images |
396 |
385 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
966 |
937 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
190 |
184 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
253 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
51 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
60 |
43 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
717 |
694 |
$3K |
| D4342 |
|
15 |
12 |
$3K |
| D2750 |
|
12 |
12 |
$3K |
| D0270 |
|
175 |
171 |
$963.20 |
| D0272 |
Bitewings - two radiographic images |
46 |
41 |
$500.00 |