| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4342 |
|
364 |
130 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
100 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
545 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
687 |
687 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,053 |
1,043 |
$13K |
| D1110 |
Prophylaxis - adult |
285 |
285 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
128 |
128 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
575 |
575 |
$10K |
| D0274 |
Bitewings - four radiographic images |
260 |
260 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
30 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
13 |
$4K |
| D4910 |
|
12 |
12 |
$807.36 |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$616.43 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$476.53 |