| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
566 |
560 |
$20K |
| D0274 |
Bitewings - four radiographic images |
488 |
484 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
122 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
428 |
425 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
320 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
233 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
846 |
794 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
40 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
548 |
540 |
$4K |
| D2332 |
|
37 |
27 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
29 |
$3K |
| D2954 |
|
29 |
27 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
96 |
93 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
52 |
$1K |
| D0270 |
|
14 |
14 |
$104.24 |