| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
323 |
321 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,609 |
490 |
$11K |
| D1110 |
Prophylaxis - adult |
114 |
114 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
125 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
455 |
449 |
$6K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |