| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
821 |
196 |
$58K |
| D1110 |
Prophylaxis - adult |
1,416 |
1,338 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
2,080 |
1,672 |
$45K |
| D2335 |
|
380 |
75 |
$43K |
| D5640 |
|
253 |
40 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,222 |
1,161 |
$21K |
| D0274 |
Bitewings - four radiographic images |
829 |
788 |
$18K |
| D5630 |
|
135 |
40 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
479 |
192 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
44 |
$2K |
| D0470 |
|
51 |
45 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
338 |
318 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
97 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$240.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |