| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
516 |
155 |
$53K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
128 |
42 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
633 |
611 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
486 |
469 |
$9K |
| D1120 |
Prophylaxis - child |
300 |
291 |
$8K |
| D1999 |
|
483 |
454 |
$3K |
| D1110 |
Prophylaxis - adult |
42 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
128 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
113 |
103 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$726.00 |
| D0330 |
Panoramic radiographic image |
17 |
16 |
$686.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$264.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$216.00 |