| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
916 |
487 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,031 |
1,831 |
$45K |
| D1110 |
Prophylaxis - adult |
1,309 |
1,174 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
194 |
122 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,414 |
1,279 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,372 |
1,258 |
$18K |
| D0274 |
Bitewings - four radiographic images |
616 |
562 |
$17K |
| D1120 |
Prophylaxis - child |
637 |
601 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,297 |
1,068 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
116 |
$13K |
| D0272 |
Bitewings - two radiographic images |
140 |
136 |
$2K |
| D0330 |
Panoramic radiographic image |
51 |
44 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$398.28 |
| D1330 |
|
406 |
390 |
$0.00 |