| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
137 |
57 |
$24K |
| D2394 |
|
113 |
50 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
695 |
251 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
302 |
275 |
$5K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$4K |
| D0274 |
Bitewings - four radiographic images |
91 |
91 |
$3K |
| D1320 |
|
81 |
81 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$3K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$838.27 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$736.88 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$401.93 |