| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,488 |
941 |
$98K |
| D0350 |
|
7,690 |
2,935 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,013 |
1,012 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
983 |
982 |
$45K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
518 |
388 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
569 |
411 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
747 |
744 |
$29K |
| D1110 |
Prophylaxis - adult |
241 |
241 |
$21K |
| D1120 |
Prophylaxis - child |
690 |
689 |
$20K |
| D0274 |
Bitewings - four radiographic images |
637 |
634 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,140 |
1,228 |
$12K |
| D1206 |
Topical application of fluoride varnish |
901 |
901 |
$11K |
| D9430 |
|
170 |
168 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
270 |
268 |
$2K |
| D0270 |
|
92 |
91 |
$455.00 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
42 |
$444.00 |
| D1999 |
|
51 |
49 |
$0.00 |