| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
562 |
168 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
488 |
484 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,090 |
828 |
$17K |
| D1110 |
Prophylaxis - adult |
171 |
169 |
$13K |
| D1120 |
Prophylaxis - child |
364 |
357 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
843 |
835 |
$10K |
| D0272 |
Bitewings - two radiographic images |
496 |
492 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
117 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
94 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
26 |
$3K |
| D0350 |
|
196 |
137 |
$3K |
| D1206 |
Topical application of fluoride varnish |
188 |
187 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$518.40 |
| D9993 |
|
16 |
16 |
$0.00 |