| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,378 |
348 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,013 |
331 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
866 |
296 |
$57K |
| D2394 |
|
333 |
142 |
$37K |
| D1110 |
Prophylaxis - adult |
498 |
380 |
$19K |
| D0330 |
Panoramic radiographic image |
361 |
270 |
$15K |
| D0274 |
Bitewings - four radiographic images |
581 |
453 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
336 |
275 |
$11K |
| D1206 |
Topical application of fluoride varnish |
586 |
458 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
635 |
484 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
178 |
136 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
633 |
465 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
246 |
178 |
$5K |
| D2335 |
|
24 |
12 |
$3K |
| D9951 |
|
53 |
35 |
$3K |
| D3120 |
|
75 |
28 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$583.20 |
| D1999 |
|
60 |
43 |
$0.00 |