| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
738 |
736 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
383 |
219 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,097 |
1,094 |
$20K |
| D9630 |
|
976 |
973 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
305 |
160 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,293 |
566 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
920 |
895 |
$15K |
| D4910 |
|
197 |
197 |
$14K |
| D4341 |
|
141 |
60 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
445 |
442 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
289 |
282 |
$10K |
| D0274 |
Bitewings - four radiographic images |
346 |
344 |
$10K |
| D0170 |
|
307 |
307 |
$8K |
| D1330 |
|
690 |
689 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$7K |
| D0603 |
|
336 |
336 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0602 |
|
39 |
38 |
$407.00 |
| D0270 |
|
13 |
13 |
$143.00 |