| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
301 |
105 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,366 |
1,357 |
$24K |
| D1120 |
Prophylaxis - child |
666 |
660 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,080 |
1,072 |
$17K |
| D1110 |
Prophylaxis - adult |
327 |
327 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
294 |
$9K |
| D0330 |
Panoramic radiographic image |
200 |
200 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
315 |
287 |
$4K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$3K |
| D4910 |
|
194 |
194 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
95 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
114 |
$584.67 |