| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,326 |
556 |
$179K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,599 |
1,596 |
$64K |
| D1110 |
Prophylaxis - adult |
1,377 |
1,371 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
544 |
249 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
614 |
612 |
$49K |
| D2740 |
Crown - porcelain/ceramic |
64 |
39 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,010 |
1,007 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
104 |
56 |
$18K |
| D2950 |
|
105 |
67 |
$14K |
| D7240 |
Removal of impacted tooth - completely bony |
45 |
13 |
$13K |
| D4341 |
|
44 |
14 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
347 |
345 |
$11K |
| D2332 |
|
78 |
26 |
$11K |
| D0330 |
Panoramic radiographic image |
162 |
162 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
25 |
$8K |
| D1206 |
Topical application of fluoride varnish |
398 |
398 |
$7K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
69 |
$842.58 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$184.80 |