| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
506 |
185 |
$39K |
| D1110 |
Prophylaxis - adult |
1,065 |
1,053 |
$29K |
| D0330 |
Panoramic radiographic image |
390 |
387 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
746 |
740 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
390 |
173 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
607 |
598 |
$7K |
| D1120 |
Prophylaxis - child |
218 |
215 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,030 |
1,020 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
433 |
427 |
$845.29 |
| D0140 |
Limited oral evaluation - problem focused |
81 |
78 |
$801.72 |
| D1330 |
|
1,318 |
1,301 |
$742.41 |
| D0230 |
Intraoral - periapical each additional radiographic image |
810 |
796 |
$661.83 |
| D0220 |
Intraoral - periapical first radiographic image |
944 |
931 |
$335.77 |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$320.98 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
29 |
$289.70 |
| D0240 |
|
14 |
14 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$0.00 |