| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
370 |
370 |
$28K |
| D1110 |
Prophylaxis - adult |
290 |
288 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
409 |
402 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,026 |
909 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
790 |
783 |
$11K |
| D2160 |
|
118 |
63 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
420 |
376 |
$5K |
| D4341 |
|
42 |
12 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
103 |
$1K |
| D1120 |
Prophylaxis - child |
36 |
36 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$792.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$626.40 |