| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
130 |
74 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
364 |
361 |
$9K |
| D1120 |
Prophylaxis - child |
215 |
215 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
85 |
$7K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
81 |
$5K |
| D1351 |
Sealant - per tooth |
68 |
31 |
$5K |
| D1206 |
Topical application of fluoride varnish |
189 |
189 |
$4K |
| D0274 |
Bitewings - four radiographic images |
198 |
198 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
134 |
$3K |
| D4342 |
|
27 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
460 |
456 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
356 |
354 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
67 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$1K |
| D9110 |
|
14 |
13 |
$715.00 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$686.70 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$144.17 |