| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
824 |
419 |
$43K |
| D1110 |
Prophylaxis - adult |
874 |
869 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
649 |
642 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
376 |
$6K |
| D0274 |
Bitewings - four radiographic images |
1,034 |
1,021 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,072 |
1,065 |
$2K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
559 |
525 |
$791.21 |
| D0140 |
Limited oral evaluation - problem focused |
55 |
54 |
$370.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
28 |
$136.00 |
| D1330 |
|
412 |
411 |
$127.00 |