| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
492 |
148 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
316 |
314 |
$23K |
| D1110 |
Prophylaxis - adult |
266 |
265 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
329 |
327 |
$569.67 |
| D1208 |
Topical application of fluoride, excluding varnish |
424 |
421 |
$439.48 |
| D1330 |
|
430 |
427 |
$93.98 |
| D0274 |
Bitewings - four radiographic images |
15 |
13 |
$46.86 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
43 |
$5.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
13 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
16 |
$0.00 |