| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
967 |
957 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,410 |
1,396 |
$26K |
| D0274 |
Bitewings - four radiographic images |
770 |
760 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,409 |
1,397 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,320 |
1,306 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
239 |
167 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
102 |
$9K |
| D1120 |
Prophylaxis - child |
270 |
267 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
603 |
597 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
977 |
962 |
$6K |
| D4341 |
|
33 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$612.00 |