| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,143 |
484 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
690 |
344 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
620 |
614 |
$36K |
| D0350 |
|
2,879 |
698 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
570 |
564 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
358 |
358 |
$23K |
| D1110 |
Prophylaxis - adult |
276 |
276 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
757 |
750 |
$9K |
| D0274 |
Bitewings - four radiographic images |
383 |
382 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,458 |
852 |
$6K |
| D2330 |
|
26 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
63 |
62 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
68 |
$840.00 |
| D9430 |
|
25 |
24 |
$800.00 |
| D1999 |
|
146 |
129 |
$0.00 |