| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,462 |
828 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,520 |
737 |
$23K |
| D1120 |
Prophylaxis - child |
2,478 |
2,174 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,614 |
1,491 |
$15K |
| D1351 |
Sealant - per tooth |
1,345 |
360 |
$12K |
| D1206 |
Topical application of fluoride varnish |
2,263 |
1,999 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
971 |
930 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
374 |
260 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
3,033 |
2,562 |
$8K |
| D4341 |
|
865 |
299 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
1,868 |
1,625 |
$6K |
| D9110 |
|
814 |
633 |
$3K |
| D1110 |
Prophylaxis - adult |
259 |
256 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,385 |
2,024 |
$3K |
| D0274 |
Bitewings - four radiographic images |
809 |
792 |
$3K |
| D0160 |
|
34 |
26 |
$2K |
| D2332 |
|
125 |
69 |
$2K |
| D0272 |
Bitewings - two radiographic images |
279 |
266 |
$1K |
| D9430 |
|
480 |
395 |
$1K |
| D4342 |
|
62 |
37 |
$770.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
19 |
$760.00 |
| D0140 |
Limited oral evaluation - problem focused |
483 |
425 |
$490.00 |
| D2330 |
|
17 |
14 |
$240.00 |
| D2940 |
|
126 |
100 |
$225.00 |
| D7250 |
|
22 |
12 |
$200.00 |
| D0270 |
|
20 |
19 |
$20.00 |
| D1310 |
|
1,668 |
1,275 |
$0.00 |
| D0603 |
|
500 |
351 |
$0.00 |
| D1330 |
|
2,434 |
1,999 |
$0.00 |
| D0601 |
|
596 |
449 |
$0.00 |
| D0602 |
|
272 |
183 |
$0.00 |
| D1999 |
|
46 |
45 |
$0.00 |
| D9993 |
|
1,672 |
1,239 |
$0.00 |
| D9910 |
|
283 |
249 |
$0.00 |