| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
123 |
31 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
15 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
17 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
92 |
92 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
45 |
$886.71 |
| D0140 |
Limited oral evaluation - problem focused |
44 |
41 |
$793.98 |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
112 |
$789.00 |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$712.44 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$452.55 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$290.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
137 |
99 |
$207.90 |