| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
3,244 |
1,187 |
$173K |
| D1110 |
Prophylaxis - adult |
4,203 |
4,169 |
$62K |
| D2335 |
|
1,130 |
515 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
4,504 |
4,462 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,729 |
3,987 |
$23K |
| D2332 |
|
344 |
203 |
$17K |
| D0274 |
Bitewings - four radiographic images |
3,469 |
3,426 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
221 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
1,021 |
1,020 |
$13K |
| D1120 |
Prophylaxis - child |
654 |
650 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
4,447 |
4,378 |
$8K |
| D1206 |
Topical application of fluoride varnish |
761 |
755 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,223 |
1,201 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
582 |
573 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,040 |
1,039 |
$8K |
| D4341 |
|
307 |
141 |
$7K |
| D1351 |
Sealant - per tooth |
249 |
39 |
$2K |
| D2750 |
|
17 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$320.00 |
| D2950 |
|
12 |
12 |
$275.00 |
| D2394 |
|
96 |
50 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$0.00 |