| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,219 |
547 |
$65K |
| D1110 |
Prophylaxis - adult |
2,257 |
2,201 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,196 |
2,127 |
$26K |
| D1120 |
Prophylaxis - child |
848 |
825 |
$22K |
| D0330 |
Panoramic radiographic image |
766 |
753 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
921 |
909 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
730 |
273 |
$10K |
| D0274 |
Bitewings - four radiographic images |
2,145 |
2,071 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,748 |
1,616 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,686 |
1,644 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,166 |
1,520 |
$1K |
| D1330 |
|
2,663 |
2,603 |
$899.02 |
| D0350 |
|
539 |
525 |
$265.42 |
| D0272 |
Bitewings - two radiographic images |
420 |
414 |
$252.24 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$32.04 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
54 |
$0.00 |
| D3120 |
|
49 |
14 |
$0.00 |
| D2394 |
|
139 |
60 |
$0.00 |