| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
653 |
260 |
$57K |
| D4910 |
|
319 |
316 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
561 |
561 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,005 |
1,004 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
504 |
504 |
$13K |
| D1110 |
Prophylaxis - adult |
238 |
238 |
$11K |
| D0274 |
Bitewings - four radiographic images |
777 |
776 |
$11K |
| D0330 |
Panoramic radiographic image |
634 |
633 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
237 |
235 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
29 |
$4K |
| D0603 |
|
13 |
13 |
$33.00 |