| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
678 |
500 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,311 |
821 |
$45K |
| D1110 |
Prophylaxis - adult |
1,680 |
1,642 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
574 |
565 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
927 |
911 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,023 |
999 |
$4K |
| D1206 |
Topical application of fluoride varnish |
1,875 |
1,835 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
80 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,093 |
741 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
176 |
$1K |
| D0274 |
Bitewings - four radiographic images |
575 |
564 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$979.46 |
| D0220 |
Intraoral - periapical first radiographic image |
966 |
935 |
$643.99 |
| D1330 |
|
1,805 |
1,771 |
$559.40 |
| D2331 |
|
13 |
12 |
$287.54 |
| D9986 |
|
671 |
651 |
$27.32 |
| D9987 |
|
199 |
188 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$0.00 |