| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9944 |
|
63 |
59 |
$22K |
| D1110 |
Prophylaxis - adult |
336 |
336 |
$19K |
| D0350 |
|
335 |
334 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
599 |
598 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
24 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
27 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
411 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
763 |
734 |
$11K |
| D0274 |
Bitewings - four radiographic images |
320 |
319 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
589 |
501 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$5K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$2K |
| D0460 |
|
86 |
86 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |
| D4346 |
|
13 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$544.00 |