| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,713 |
805 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
1,286 |
1,278 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,376 |
1,371 |
$90K |
| D1110 |
Prophylaxis - adult |
838 |
831 |
$74K |
| D1120 |
Prophylaxis - child |
1,147 |
1,141 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
1,027 |
1,024 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,077 |
2,064 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,243 |
1,237 |
$26K |
| D9430 |
|
599 |
574 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,264 |
1,656 |
$13K |
| D4910 |
|
136 |
136 |
$10K |
| D4341 |
|
114 |
44 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
612 |
587 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
40 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$928.20 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$288.00 |
| D1320 |
|
16 |
16 |
$280.00 |
| D1310 |
|
43 |
43 |
$0.00 |
| D1330 |
|
23 |
23 |
$0.00 |
| D0601 |
|
25 |
25 |
$0.00 |
| D1999 |
|
14 |
14 |
$0.00 |