| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
401 |
399 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
442 |
194 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
253 |
122 |
$17K |
| D0350 |
|
1,160 |
379 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,003 |
447 |
$8K |
| D9430 |
|
142 |
136 |
$5K |
| D1206 |
Topical application of fluoride varnish |
310 |
308 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
67 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
244 |
$3K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$2K |
| D0272 |
Bitewings - two radiographic images |
97 |
96 |
$1K |