| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
1,259 |
1,184 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
663 |
359 |
$55K |
| D1110 |
Prophylaxis - adult |
1,551 |
1,540 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,936 |
1,891 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
575 |
282 |
$42K |
| D5110 |
|
24 |
24 |
$16K |
| D0330 |
Panoramic radiographic image |
328 |
308 |
$16K |
| D2950 |
|
158 |
126 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
79 |
25 |
$11K |
| D3320 |
|
19 |
12 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
651 |
651 |
$7K |
| D7880 |
|
16 |
16 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
26 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
253 |
252 |
$5K |
| D0274 |
Bitewings - four radiographic images |
184 |
183 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
73 |
$2K |
| D9630 |
|
352 |
351 |
$826.56 |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
93 |
$687.47 |
| D9994 |
|
350 |
348 |
$0.00 |