| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
153 |
40 |
$6K |
| D1110 |
Prophylaxis - adult |
455 |
453 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
376 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
351 |
348 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
29 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
109 |
$3K |
| D0274 |
Bitewings - four radiographic images |
580 |
574 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
126 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
553 |
491 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
331 |
312 |
$738.00 |
| D0603 |
|
501 |
496 |
$610.00 |
| D4346 |
|
14 |
14 |
$490.00 |
| D1206 |
Topical application of fluoride varnish |
34 |
33 |
$420.00 |
| D0330 |
Panoramic radiographic image |
126 |
124 |
$198.00 |
| D1330 |
|
24 |
23 |
$0.00 |