| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
882 |
436 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,092 |
1,060 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
396 |
392 |
$16K |
| D1110 |
Prophylaxis - adult |
238 |
231 |
$12K |
| D1120 |
Prophylaxis - child |
533 |
528 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
113 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,431 |
1,360 |
$8K |
| D0330 |
Panoramic radiographic image |
447 |
427 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,142 |
1,049 |
$5K |
| D0274 |
Bitewings - four radiographic images |
625 |
613 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
32 |
32 |
$4K |
| D1206 |
Topical application of fluoride varnish |
83 |
83 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
25 |
$2K |
| D1999 |
|
13 |
13 |
$780.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$720.00 |
| D0140 |
Limited oral evaluation - problem focused |
110 |
101 |
$280.00 |
| D0270 |
|
66 |
64 |
$135.00 |
| D1330 |
|
206 |
200 |
$0.00 |