| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,198 |
295 |
$67K |
| D4341 |
|
354 |
141 |
$32K |
| D1110 |
Prophylaxis - adult |
621 |
621 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,458 |
1,455 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
772 |
741 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
856 |
856 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
408 |
408 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
523 |
$20K |
| D4910 |
|
264 |
264 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,224 |
1,177 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
70 |
$9K |
| D0274 |
Bitewings - four radiographic images |
292 |
292 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
824 |
718 |
$7K |
| D0603 |
|
646 |
644 |
$7K |
| D0602 |
|
156 |
156 |
$2K |
| D4342 |
|
27 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$323.00 |
| D1330 |
|
27 |
27 |
$200.00 |
| D1999 |
|
61 |
59 |
$0.00 |