| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
777 |
329 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,298 |
1,228 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,426 |
1,346 |
$26K |
| D1110 |
Prophylaxis - adult |
880 |
830 |
$26K |
| D1120 |
Prophylaxis - child |
495 |
471 |
$20K |
| D2140 |
|
405 |
165 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
365 |
333 |
$18K |
| D0274 |
Bitewings - four radiographic images |
563 |
547 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
244 |
97 |
$15K |
| D2330 |
|
202 |
97 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
101 |
63 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
42 |
$5K |
| D1351 |
Sealant - per tooth |
125 |
33 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
368 |
273 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
87 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
82 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
14 |
$2K |
| D2331 |
|
19 |
12 |
$1K |
| D2950 |
|
25 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
13 |
$241.40 |