| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,163 |
192 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
877 |
223 |
$56K |
| D9430 |
|
1,561 |
911 |
$48K |
| D1120 |
Prophylaxis - child |
849 |
835 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
565 |
560 |
$24K |
| D2330 |
|
286 |
76 |
$22K |
| D2331 |
|
256 |
60 |
$21K |
| D1206 |
Topical application of fluoride varnish |
906 |
885 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,390 |
1,036 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
208 |
$11K |
| D0274 |
Bitewings - four radiographic images |
158 |
157 |
$3K |
| D2160 |
|
38 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
67 |
$3K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$156.00 |
| D1999 |
|
65 |
47 |
$92.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$0.00 |
| D1201 |
|
15 |
15 |
$0.00 |