| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,632 |
1,713 |
$169K |
| D1110 |
Prophylaxis - adult |
1,538 |
1,530 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
2,047 |
2,039 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,844 |
1,835 |
$113K |
| D0210 |
Intraoral - complete series of radiographic images |
2,014 |
2,010 |
$93K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
795 |
634 |
$60K |
| D1120 |
Prophylaxis - child |
1,380 |
1,377 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,824 |
1,814 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,591 |
2,316 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,300 |
1,300 |
$18K |
| D4341 |
|
244 |
64 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
314 |
203 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
125 |
82 |
$14K |
| D0350 |
|
1,524 |
987 |
$14K |
| D4910 |
|
42 |
42 |
$3K |
| D2330 |
|
21 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$132.00 |
| D0270 |
|
13 |
13 |
$65.00 |
| D0703 |
|
29 |
28 |
$0.00 |
| D1999 |
|
48 |
48 |
$0.00 |