| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
547 |
147 |
$158K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
588 |
202 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
2,716 |
2,712 |
$132K |
| D2740 |
Crown - porcelain/ceramic |
74 |
46 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
160 |
$92K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,518 |
2,308 |
$87K |
| D1120 |
Prophylaxis - child |
1,742 |
1,739 |
$63K |
| D1110 |
Prophylaxis - adult |
742 |
740 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,938 |
1,933 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,954 |
2,945 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
308 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
813 |
744 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
14 |
$8K |
| D1351 |
Sealant - per tooth |
214 |
48 |
$4K |
| D9430 |
|
12 |
12 |
$336.00 |