| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
843 |
843 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
373 |
249 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
497 |
497 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
906 |
905 |
$26K |
| D0274 |
Bitewings - four radiographic images |
744 |
744 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
639 |
639 |
$18K |
| D4341 |
|
227 |
90 |
$15K |
| D4910 |
|
212 |
212 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
850 |
846 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
244 |
244 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
318 |
318 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
50 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
305 |
305 |
$4K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$3K |
| D1351 |
Sealant - per tooth |
72 |
17 |
$3K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$684.00 |