| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,237 |
711 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,193 |
594 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,155 |
1,153 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
562 |
562 |
$33K |
| D1120 |
Prophylaxis - child |
696 |
696 |
$22K |
| D1110 |
Prophylaxis - adult |
217 |
217 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,609 |
1,608 |
$19K |
| D0274 |
Bitewings - four radiographic images |
892 |
891 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,568 |
1,484 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
260 |
260 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
197 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D9430 |
|
12 |
12 |
$336.00 |
| D0350 |
|
38 |
15 |
$222.00 |