| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
15 |
$4K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
31 |
$2K |
| D0180 |
|
25 |
25 |
$2K |
| D3120 |
|
45 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
40 |
$1K |
| D1206 |
Topical application of fluoride varnish |
23 |
17 |
$584.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
28 |
$503.75 |