| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
281 |
111 |
$20K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
198 |
197 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
315 |
$5K |
| D0274 |
Bitewings - four radiographic images |
153 |
153 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
420 |
269 |
$3K |
| D1120 |
Prophylaxis - child |
70 |
69 |
$3K |
| D2330 |
|
36 |
16 |
$2K |
| D4355 |
|
32 |
32 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
41 |
$1K |