| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,805 |
1,801 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,302 |
720 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
953 |
952 |
$58K |
| D1120 |
Prophylaxis - child |
1,557 |
1,556 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
801 |
447 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
836 |
835 |
$39K |
| D1110 |
Prophylaxis - adult |
361 |
360 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,461 |
2,231 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,432 |
2,429 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,725 |
1,721 |
$20K |
| D0350 |
|
1,994 |
918 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
147 |
$2K |
| D9430 |
|
45 |
45 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$777.60 |