| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
250 |
122 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
199 |
133 |
$21K |
| D1110 |
Prophylaxis - adult |
367 |
366 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
562 |
561 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
217 |
$14K |
| D2750 |
|
27 |
14 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
533 |
533 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
39 |
$7K |
| D0274 |
Bitewings - four radiographic images |
204 |
203 |
$7K |
| D0180 |
|
86 |
85 |
$5K |
| D1120 |
Prophylaxis - child |
107 |
107 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
74 |
$3K |
| D4355 |
|
31 |
31 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
191 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
25 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
132 |
99 |
$1K |