| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
904 |
528 |
$49K |
| D4341 |
|
267 |
100 |
$40K |
| D1120 |
Prophylaxis - child |
1,015 |
965 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
965 |
904 |
$25K |
| D1351 |
Sealant - per tooth |
618 |
218 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
947 |
893 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
660 |
371 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
748 |
711 |
$15K |
| D0274 |
Bitewings - four radiographic images |
825 |
768 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
172 |
129 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,497 |
1,398 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,544 |
1,300 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
95 |
69 |
$6K |
| D1110 |
Prophylaxis - adult |
120 |
112 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
145 |
$4K |
| D4910 |
|
34 |
33 |
$2K |
| D1206 |
Topical application of fluoride varnish |
73 |
71 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
104 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
16 |
$1K |
| D2330 |
|
25 |
12 |
$865.00 |
| D0272 |
Bitewings - two radiographic images |
81 |
78 |
$667.40 |
| D9110 |
|
12 |
12 |
$605.00 |
| D1999 |
|
26 |
25 |
$0.00 |