| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,280 |
634 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,176 |
1,174 |
$74K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
305 |
196 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
442 |
238 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
486 |
486 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,119 |
1,113 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,478 |
1,254 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
447 |
446 |
$18K |
| D4341 |
|
166 |
45 |
$12K |
| D1120 |
Prophylaxis - child |
269 |
268 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
12 |
$3K |
| D4910 |
|
29 |
29 |
$2K |
| D4342 |
|
45 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |