| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
602 |
597 |
$53K |
| D4910 |
|
346 |
344 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
306 |
304 |
$23K |
| D4341 |
|
304 |
81 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
279 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
854 |
848 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,850 |
427 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$3K |
| D0272 |
Bitewings - two radiographic images |
135 |
135 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$993.00 |
| D0350 |
|
43 |
27 |
$412.80 |