| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
185 |
74 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
232 |
$10K |
| D1110 |
Prophylaxis - adult |
171 |
163 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
43 |
$7K |
| D0330 |
Panoramic radiographic image |
196 |
183 |
$6K |
| D1206 |
Topical application of fluoride varnish |
242 |
232 |
$5K |
| D0274 |
Bitewings - four radiographic images |
263 |
245 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
350 |
324 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
280 |
258 |
$635.49 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
12 |
$396.86 |