| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
117 |
68 |
$27K |
| D2750 |
|
60 |
48 |
$15K |
| D1120 |
Prophylaxis - child |
373 |
336 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
145 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
468 |
423 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
320 |
282 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
323 |
293 |
$8K |
| D1110 |
Prophylaxis - adult |
162 |
159 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
198 |
$6K |
| D0274 |
Bitewings - four radiographic images |
288 |
261 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
734 |
641 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
80 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
217 |
$4K |
| D2950 |
|
62 |
50 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
37 |
$3K |
| D1351 |
Sealant - per tooth |
20 |
17 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
549 |
478 |
$2K |
| D0270 |
|
146 |
135 |
$817.60 |
| D0272 |
Bitewings - two radiographic images |
52 |
47 |
$488.80 |