| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
382 |
206 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,071 |
1,070 |
$25K |
| D1120 |
Prophylaxis - child |
478 |
478 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
571 |
565 |
$18K |
| D1110 |
Prophylaxis - adult |
332 |
331 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
107 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
379 |
379 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
329 |
328 |
$9K |
| D0274 |
Bitewings - four radiographic images |
449 |
448 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
424 |
401 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
980 |
965 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
79 |
$5K |
| D1351 |
Sealant - per tooth |
30 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
729 |
725 |
$3K |
| D4910 |
|
26 |
26 |
$2K |
| D0270 |
|
102 |
101 |
$571.20 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$354.88 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$327.60 |