| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
1,732 |
1,306 |
$619K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,896 |
2,235 |
$545K |
| D1110 |
Prophylaxis - adult |
9,551 |
9,544 |
$319K |
| D0274 |
Bitewings - four radiographic images |
8,848 |
8,847 |
$156K |
| D2954 |
|
1,590 |
1,202 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
5,941 |
5,938 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,439 |
5,437 |
$112K |
| D0220 |
Intraoral - periapical first radiographic image |
11,679 |
11,629 |
$103K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,915 |
10,897 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,522 |
814 |
$93K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
287 |
257 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
5,072 |
4,956 |
$32K |
| D3320 |
|
182 |
159 |
$32K |
| D1120 |
Prophylaxis - child |
766 |
765 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
164 |
$16K |
| D4341 |
|
387 |
151 |
$14K |
| D0330 |
Panoramic radiographic image |
1,233 |
1,233 |
$12K |
| D9945 |
|
116 |
116 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
815 |
814 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
145 |
120 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
661 |
656 |
$6K |
| D1351 |
Sealant - per tooth |
19 |
13 |
$1K |
| D0350 |
|
100 |
100 |
$880.94 |
| D1999 |
|
90 |
68 |
$0.00 |