| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
1,740 |
436 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,749 |
1,733 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
865 |
865 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
650 |
644 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
459 |
202 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
318 |
170 |
$15K |
| D1120 |
Prophylaxis - child |
494 |
489 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,375 |
1,356 |
$10K |
| D0274 |
Bitewings - four radiographic images |
872 |
867 |
$9K |
| D1110 |
Prophylaxis - adult |
169 |
168 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
258 |
254 |
$5K |
| D1999 |
|
718 |
646 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
90 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,214 |
1,118 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
12 |
$1K |
| D4910 |
|
17 |
17 |
$782.00 |