| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
167 |
31 |
$450.00 |
| D4346 |
|
115 |
68 |
$380.00 |
| D0330 |
Panoramic radiographic image |
29 |
21 |
$180.00 |
| D1206 |
Topical application of fluoride varnish |
209 |
127 |
$108.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
186 |
46 |
$49.00 |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
60 |
$33.00 |
| D0274 |
Bitewings - four radiographic images |
116 |
69 |
$30.00 |
| D1120 |
Prophylaxis - child |
33 |
20 |
$0.00 |
| D4910 |
|
25 |
16 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
24 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
35 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
21 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
19 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
141 |
82 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
15 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
17 |
$0.00 |