| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,226 |
465 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,068 |
1,068 |
$70K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
488 |
198 |
$38K |
| D9430 |
|
961 |
851 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
659 |
659 |
$29K |
| D1120 |
Prophylaxis - child |
664 |
663 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
331 |
330 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
277 |
135 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
912 |
909 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,365 |
1,066 |
$10K |
| D1110 |
Prophylaxis - adult |
39 |
38 |
$3K |
| D0272 |
Bitewings - two radiographic images |
234 |
234 |
$3K |
| D1351 |
Sealant - per tooth |
99 |
29 |
$2K |
| D0274 |
Bitewings - four radiographic images |
55 |
54 |
$961.20 |
| D0350 |
|
96 |
33 |
$854.40 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$348.00 |