| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
1,010 |
1,005 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,810 |
2,795 |
$70K |
| D1110 |
Prophylaxis - adult |
1,104 |
1,097 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,674 |
1,667 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
141 |
$34K |
| D4342 |
|
270 |
111 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
98 |
$20K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
37 |
29 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,007 |
997 |
$15K |
| D0330 |
Panoramic radiographic image |
190 |
190 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
507 |
496 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
155 |
$6K |
| D1120 |
Prophylaxis - child |
89 |
89 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
78 |
$3K |
| D2950 |
|
14 |
14 |
$2K |