| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,149 |
411 |
$91K |
| D2332 |
|
1,054 |
431 |
$87K |
| D0350 |
|
9,408 |
2,230 |
$86K |
| D1110 |
Prophylaxis - adult |
667 |
667 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
796 |
791 |
$50K |
| D4910 |
|
471 |
471 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
724 |
718 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,353 |
1,119 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,024 |
1,009 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
171 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
429 |
418 |
$5K |
| D2394 |
|
56 |
31 |
$5K |
| D0274 |
Bitewings - four radiographic images |
121 |
121 |
$2K |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$878.00 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$735.00 |