| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,029 |
1,272 |
$251K |
| D2394 |
|
2,482 |
976 |
$247K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,583 |
988 |
$238K |
| D9420 |
|
3,055 |
2,801 |
$238K |
| D4210 |
|
2,413 |
677 |
$212K |
| D4999 |
|
1,132 |
1,128 |
$182K |
| D0120 |
Periodic oral evaluation - established patient |
2,215 |
2,203 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
889 |
884 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
576 |
338 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,089 |
1,079 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
404 |
236 |
$34K |
| D1110 |
Prophylaxis - adult |
673 |
654 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
399 |
107 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,135 |
1,121 |
$16K |
| D2332 |
|
179 |
92 |
$16K |
| D2335 |
|
92 |
60 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
283 |
279 |
$10K |
| D0350 |
|
588 |
585 |
$7K |
| D2330 |
|
112 |
69 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
152 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$340.20 |