| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,603 |
549 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,547 |
1,540 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
1,109 |
1,102 |
$76K |
| D1110 |
Prophylaxis - adult |
698 |
698 |
$62K |
| D1120 |
Prophylaxis - child |
1,394 |
1,384 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,765 |
2,499 |
$51K |
| D4910 |
|
553 |
546 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
694 |
255 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,555 |
2,545 |
$34K |
| D0350 |
|
3,036 |
798 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,248 |
1,237 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
521 |
521 |
$25K |
| D1351 |
Sealant - per tooth |
488 |
118 |
$17K |
| D9430 |
|
237 |
231 |
$8K |
| D0330 |
Panoramic radiographic image |
206 |
206 |
$6K |
| D4341 |
|
42 |
12 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
36 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$684.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$468.00 |