| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,678 |
1,669 |
$143K |
| D0120 |
Periodic oral evaluation - established patient |
2,391 |
2,374 |
$137K |
| D4910 |
|
1,077 |
1,071 |
$82K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,351 |
3,330 |
$44K |
| D1120 |
Prophylaxis - child |
582 |
574 |
$19K |
| D4341 |
|
146 |
40 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
180 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
50 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
839 |
231 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
198 |
$2K |
| D2330 |
|
25 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |