| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
118 |
63 |
$20K |
| D1110 |
Prophylaxis - adult |
286 |
284 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
456 |
451 |
$14K |
| D1206 |
Topical application of fluoride varnish |
541 |
536 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
55 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
154 |
$7K |
| D0274 |
Bitewings - four radiographic images |
231 |
230 |
$5K |
| D1120 |
Prophylaxis - child |
88 |
88 |
$4K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
266 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
151 |
$1K |
| D1330 |
|
67 |
67 |
$482.40 |