| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3310 |
|
34 |
14 |
$7K |
| D1110 |
Prophylaxis - adult |
191 |
180 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
31 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
141 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
32 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
67 |
$5K |
| D2335 |
|
42 |
14 |
$4K |
| D0330 |
Panoramic radiographic image |
70 |
63 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
77 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
130 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
117 |
$2K |
| D4355 |
|
15 |
12 |
$841.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
33 |
$811.63 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$700.55 |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
20 |
$345.80 |