| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2335 |
|
1,037 |
307 |
$114K |
| D9110 |
|
490 |
435 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
393 |
231 |
$29K |
| D2394 |
|
307 |
177 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
144 |
$14K |
| D0350 |
|
1,604 |
369 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
152 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
107 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
18 |
$2K |
| D1110 |
Prophylaxis - adult |
33 |
32 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
39 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
222 |
40 |
$765.60 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$735.00 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$271.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
34 |
$209.20 |