| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
136 |
71 |
$25K |
| D1120 |
Prophylaxis - child |
556 |
525 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
772 |
740 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
615 |
606 |
$15K |
| D0274 |
Bitewings - four radiographic images |
663 |
654 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,929 |
1,776 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
131 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
365 |
336 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,487 |
1,375 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
105 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
320 |
311 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
62 |
51 |
$4K |
| D1110 |
Prophylaxis - adult |
78 |
78 |
$4K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$877.00 |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$585.96 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$122.20 |
| D1999 |
|
18 |
17 |
$0.00 |
| D0190 |
|
19 |
15 |
$0.00 |