| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,011 |
1,010 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,647 |
1,641 |
$50K |
| D4910 |
|
1,374 |
1,373 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,605 |
1,597 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,059 |
1,058 |
$15K |
| D4341 |
|
173 |
46 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
264 |
$9K |
| D0330 |
Panoramic radiographic image |
136 |
136 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
28 |
$5K |
| D1330 |
|
430 |
428 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
36 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
176 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$2K |
| D0502 |
|
50 |
50 |
$0.00 |
| D0350 |
|
13 |
13 |
$0.00 |
| D0602 |
|
499 |
490 |
$0.00 |
| D0603 |
|
1,666 |
1,652 |
$0.00 |