| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,054 |
1,053 |
$88K |
| D4910 |
|
496 |
496 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
403 |
403 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
373 |
$23K |
| D1206 |
Topical application of fluoride varnish |
830 |
829 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,721 |
516 |
$12K |
| D4341 |
|
153 |
40 |
$9K |
| D5750 |
|
26 |
26 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
29 |
$4K |
| D0272 |
Bitewings - two radiographic images |
291 |
291 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
263 |
263 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
225 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$3K |
| D5751 |
|
14 |
14 |
$3K |
| D5850 |
|
13 |
13 |
$910.00 |