| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
590 |
588 |
$51K |
| D4341 |
|
602 |
204 |
$42K |
| D4910 |
|
458 |
456 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
609 |
609 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
281 |
163 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
193 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
841 |
840 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,209 |
507 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
197 |
197 |
$9K |
| D2330 |
|
98 |
67 |
$7K |
| D0272 |
Bitewings - two radiographic images |
370 |
370 |
$4K |
| D1120 |
Prophylaxis - child |
141 |
141 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
232 |
230 |
$3K |
| D0350 |
|
320 |
180 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
27 |
$2K |
| D4342 |
|
31 |
12 |
$1K |
| D9110 |
|
12 |
12 |
$756.00 |
| D1999 |
|
182 |
175 |
$30.00 |