| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
652 |
651 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
552 |
552 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
828 |
826 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
27 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
80 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
673 |
671 |
$5K |
| D0272 |
Bitewings - two radiographic images |
449 |
448 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
164 |
$4K |
| D2332 |
|
16 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$133.99 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$133.80 |