| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
68 |
53 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
324 |
321 |
$9K |
| D1120 |
Prophylaxis - child |
178 |
177 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
82 |
$7K |
| D1110 |
Prophylaxis - adult |
96 |
95 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
28 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
63 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
252 |
244 |
$1K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
194 |
$1K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$1K |
| D2394 |
|
14 |
12 |
$986.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
37 |
$950.00 |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$760.13 |
| D9110 |
|
13 |
12 |
$650.00 |
| D0330 |
Panoramic radiographic image |
24 |
22 |
$293.80 |