| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
669 |
643 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
622 |
589 |
$10K |
| D0274 |
Bitewings - four radiographic images |
468 |
450 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
156 |
32 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
89 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
41 |
$5K |
| D2140 |
|
107 |
27 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
163 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
34 |
$3K |
| D2394 |
|
34 |
25 |
$2K |
| D2160 |
|
28 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
94 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
228 |
86 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$942.36 |
| D1120 |
Prophylaxis - child |
31 |
31 |
$620.00 |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
106 |
$575.00 |