| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,673 |
750 |
$112K |
| D0350 |
|
11,728 |
2,952 |
$105K |
| D1110 |
Prophylaxis - adult |
1,017 |
1,007 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
961 |
958 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
630 |
617 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
551 |
322 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
859 |
856 |
$39K |
| D4910 |
|
419 |
403 |
$32K |
| D4341 |
|
317 |
91 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,527 |
1,517 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,613 |
935 |
$19K |
| D1120 |
Prophylaxis - child |
438 |
436 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
239 |
140 |
$13K |
| D9430 |
|
422 |
385 |
$12K |
| D0274 |
Bitewings - four radiographic images |
611 |
600 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
397 |
352 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
89 |
89 |
$1K |
| D2394 |
|
14 |
12 |
$1K |
| D1320 |
|
15 |
15 |
$237.50 |