| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2940 |
|
5,771 |
1,042 |
$287K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
876 |
220 |
$135K |
| D1120 |
Prophylaxis - child |
1,462 |
1,438 |
$63K |
| D1206 |
Topical application of fluoride varnish |
2,143 |
2,106 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
785 |
773 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
810 |
794 |
$24K |
| D0460 |
|
834 |
718 |
$8K |
| D1330 |
|
1,043 |
1,023 |
$6K |
| D1110 |
Prophylaxis - adult |
99 |
97 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
13 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
44 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D4355 |
|
14 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$336.98 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$141.84 |