| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
374 |
362 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
217 |
72 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
671 |
656 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
911 |
884 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
880 |
849 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
51 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
801 |
781 |
$9K |
| D0274 |
Bitewings - four radiographic images |
259 |
249 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
108 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
184 |
$6K |
| D1120 |
Prophylaxis - child |
175 |
174 |
$6K |
| D0272 |
Bitewings - two radiographic images |
150 |
149 |
$3K |
| D0603 |
|
564 |
547 |
$0.16 |
| D0601 |
|
203 |
201 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |