| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
869 |
702 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
952 |
644 |
$23K |
| D9430 |
|
2,239 |
2,087 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,368 |
1,313 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,262 |
1,240 |
$17K |
| D1120 |
Prophylaxis - child |
1,122 |
1,097 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,112 |
1,082 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
978 |
949 |
$13K |
| D4341 |
|
703 |
308 |
$12K |
| D1110 |
Prophylaxis - adult |
407 |
397 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,883 |
2,728 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,624 |
1,698 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
86 |
$4K |
| D0274 |
Bitewings - four radiographic images |
535 |
527 |
$3K |
| D2330 |
|
60 |
37 |
$2K |
| D0999 |
Unspecified diagnostic procedure, by report |
16 |
16 |
$960.00 |
| D0272 |
Bitewings - two radiographic images |
222 |
221 |
$955.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
16 |
$640.00 |
| D0330 |
Panoramic radiographic image |
47 |
42 |
$320.00 |
| D0270 |
|
274 |
266 |
$290.00 |
| D9993 |
|
154 |
149 |
$0.00 |
| D1310 |
|
154 |
149 |
$0.00 |
| D1330 |
|
27 |
27 |
$0.00 |
| D0601 |
|
28 |
28 |
$0.00 |