| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,634 |
1,123 |
$176K |
| D1110 |
Prophylaxis - adult |
1,466 |
1,459 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
1,926 |
1,916 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,404 |
1,401 |
$88K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
959 |
551 |
$76K |
| D1120 |
Prophylaxis - child |
1,639 |
1,629 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
1,234 |
1,232 |
$56K |
| D0350 |
|
7,660 |
1,859 |
$55K |
| D1206 |
Topical application of fluoride varnish |
3,439 |
3,415 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,857 |
2,313 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,158 |
1,152 |
$24K |
| D4341 |
|
218 |
59 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
237 |
115 |
$13K |
| D1320 |
|
620 |
619 |
$10K |
| D4910 |
|
78 |
78 |
$6K |
| D2330 |
|
51 |
25 |
$4K |
| D1351 |
Sealant - per tooth |
107 |
24 |
$3K |
| D0272 |
Bitewings - two radiographic images |
253 |
252 |
$3K |
| D9430 |
|
88 |
84 |
$3K |
| D2394 |
|
32 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
146 |
$2K |
| D1310 |
|
429 |
425 |
$644.00 |
| D0603 |
|
429 |
425 |
$210.00 |