| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1320 |
|
278 |
267 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
26 |
$9K |
| D0330 |
Panoramic radiographic image |
128 |
122 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
86 |
$3K |
| D1110 |
Prophylaxis - adult |
59 |
54 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
29 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
68 |
$1K |
| D3120 |
|
24 |
13 |
$690.21 |
| D0274 |
Bitewings - four radiographic images |
16 |
15 |
$527.99 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$526.89 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$286.37 |