| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
4,060 |
1,304 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
1,892 |
1,433 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
1,323 |
1,061 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,289 |
917 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,901 |
463 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
60 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
62 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
330 |
216 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
714 |
490 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
43 |
$2K |
| D2331 |
|
44 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
147 |
104 |
$1K |
| D1110 |
Prophylaxis - adult |
30 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
63 |
54 |
$706.59 |