| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
299 |
144 |
$49K |
| D1120 |
Prophylaxis - child |
717 |
716 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
870 |
867 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
627 |
626 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
234 |
180 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
502 |
$13K |
| D0274 |
Bitewings - four radiographic images |
464 |
461 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
185 |
152 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
340 |
325 |
$6K |
| D1110 |
Prophylaxis - adult |
127 |
127 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
228 |
228 |
$5K |
| D0330 |
Panoramic radiographic image |
169 |
169 |
$4K |
| D4910 |
|
50 |
50 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
305 |
296 |
$2K |
| D1351 |
Sealant - per tooth |
27 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$177.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$62.72 |