| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
991 |
295 |
$64K |
| D1110 |
Prophylaxis - adult |
407 |
405 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
348 |
347 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
271 |
269 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
301 |
301 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
66 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,641 |
429 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
458 |
455 |
$5K |
| D4910 |
|
57 |
57 |
$4K |
| D1120 |
Prophylaxis - child |
118 |
118 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
92 |
92 |
$665.40 |