| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
1,696 |
935 |
$65K |
| D1206 |
Topical application of fluoride varnish |
4,224 |
2,735 |
$57K |
| D2740 |
Crown - porcelain/ceramic |
190 |
69 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
2,869 |
1,734 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
721 |
295 |
$38K |
| D1110 |
Prophylaxis - adult |
1,164 |
879 |
$37K |
| D4342 |
|
1,585 |
266 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,885 |
1,167 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,678 |
740 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,998 |
1,143 |
$12K |
| D0330 |
Panoramic radiographic image |
326 |
215 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
55 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
210 |
$6K |
| D2950 |
|
46 |
15 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
36 |
$756.40 |
| D1999 |
|
13 |
13 |
$0.00 |