| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
121 |
86 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
815 |
797 |
$23K |
| D1110 |
Prophylaxis - adult |
454 |
448 |
$21K |
| D1120 |
Prophylaxis - child |
400 |
398 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
319 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
100 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
316 |
305 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
218 |
$5K |
| D0274 |
Bitewings - four radiographic images |
268 |
265 |
$5K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
13 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
230 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
737 |
715 |
$4K |
| D9110 |
|
86 |
86 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
534 |
475 |
$4K |
| D0330 |
Panoramic radiographic image |
113 |
109 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$618.80 |