| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,621 |
1,886 |
$155K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,273 |
842 |
$95K |
| D0210 |
Intraoral - complete series of radiographic images |
1,852 |
1,851 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
1,565 |
1,564 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,570 |
1,271 |
$45K |
| D1110 |
Prophylaxis - adult |
1,434 |
1,433 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,094 |
2,093 |
$36K |
| D4341 |
|
805 |
320 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
1,284 |
1,237 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,481 |
2,024 |
$7K |
| D0274 |
Bitewings - four radiographic images |
1,195 |
1,194 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,468 |
2,466 |
$3K |
| D1120 |
Prophylaxis - child |
710 |
710 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,720 |
2,660 |
$1K |
| D1330 |
|
2,511 |
2,506 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
49 |
$1K |
| D2331 |
|
30 |
26 |
$622.42 |
| D0272 |
Bitewings - two radiographic images |
103 |
103 |
$410.37 |
| D0270 |
|
424 |
421 |
$125.06 |
| D3120 |
|
222 |
81 |
$90.80 |
| D1351 |
Sealant - per tooth |
48 |
16 |
$0.00 |
| D2940 |
|
35 |
20 |
$0.00 |