| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
4,772 |
934 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
274 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
385 |
385 |
$14K |
| D1120 |
Prophylaxis - child |
453 |
448 |
$13K |
| D0274 |
Bitewings - four radiographic images |
517 |
514 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
471 |
466 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
35 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
25 |
$3K |
| D2140 |
|
39 |
24 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
15 |
$1K |
| D0272 |
Bitewings - two radiographic images |
108 |
108 |
$1K |
| D0350 |
|
117 |
65 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$276.00 |