| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,191 |
701 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,312 |
1,305 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
755 |
466 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
638 |
632 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,485 |
1,612 |
$30K |
| D1120 |
Prophylaxis - child |
843 |
835 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,017 |
1,013 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
459 |
455 |
$21K |
| D1110 |
Prophylaxis - adult |
286 |
282 |
$19K |
| D0350 |
|
1,982 |
787 |
$18K |
| D4341 |
|
279 |
108 |
$17K |
| D4910 |
|
172 |
172 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
92 |
52 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,144 |
1,132 |
$10K |
| D9430 |
|
273 |
256 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
51 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
312 |
$4K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$420.00 |