| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
60 |
25 |
$5K |
| D1206 |
Topical application of fluoride varnish |
202 |
200 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
115 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
212 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
28 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
150 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$875.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$564.00 |