| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
196 |
65 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,803 |
875 |
$12K |
| D2394 |
|
58 |
24 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
983 |
911 |
$7K |
| D1110 |
Prophylaxis - adult |
265 |
259 |
$6K |
| D0274 |
Bitewings - four radiographic images |
379 |
376 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
184 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
143 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
186 |
179 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
87 |
$484.20 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |