| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9410 |
|
1,548 |
1,440 |
$144K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
836 |
205 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
336 |
126 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
755 |
745 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
45 |
$15K |
| D1110 |
Prophylaxis - adult |
297 |
288 |
$13K |
| D2335 |
|
69 |
22 |
$12K |
| D2394 |
|
54 |
28 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
450 |
445 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
25 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
492 |
$6K |
| D4342 |
|
29 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
137 |
136 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
72 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$655.64 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$471.75 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$430.49 |