| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
298 |
138 |
$37K |
| D1110 |
Prophylaxis - adult |
944 |
932 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
232 |
117 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,163 |
1,155 |
$19K |
| D1206 |
Topical application of fluoride varnish |
693 |
693 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,549 |
1,456 |
$13K |
| D0274 |
Bitewings - four radiographic images |
526 |
518 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
933 |
612 |
$7K |
| D1120 |
Prophylaxis - child |
204 |
204 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
190 |
189 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
101 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
57 |
$2K |
| D9310 |
|
24 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$806.00 |
| D3120 |
|
23 |
14 |
$423.43 |