| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,445 |
1,072 |
$269K |
| D1120 |
Prophylaxis - child |
4,437 |
4,317 |
$191K |
| D0120 |
Periodic oral evaluation - established patient |
4,797 |
4,618 |
$138K |
| D1206 |
Topical application of fluoride varnish |
5,460 |
5,229 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,241 |
647 |
$112K |
| D0274 |
Bitewings - four radiographic images |
2,872 |
2,742 |
$102K |
| D0330 |
Panoramic radiographic image |
1,425 |
1,170 |
$78K |
| D2394 |
|
461 |
244 |
$52K |
| D1110 |
Prophylaxis - adult |
1,383 |
1,277 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
658 |
634 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
464 |
419 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
94 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
733 |
602 |
$8K |
| D0272 |
Bitewings - two radiographic images |
186 |
183 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
367 |
147 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
21 |
21 |
$543.46 |
| D1999 |
|
2,804 |
2,425 |
$0.00 |