| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,151 |
1,145 |
$101K |
| D4910 |
|
1,145 |
1,141 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
1,039 |
1,035 |
$74K |
| D0350 |
|
7,170 |
2,066 |
$65K |
| D4341 |
|
659 |
177 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
704 |
697 |
$44K |
| D9430 |
|
1,232 |
1,098 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
737 |
733 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,579 |
1,574 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
119 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,068 |
1,790 |
$16K |
| D1120 |
Prophylaxis - child |
376 |
374 |
$16K |
| D0274 |
Bitewings - four radiographic images |
571 |
569 |
$11K |
| D0330 |
Panoramic radiographic image |
317 |
317 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
39 |
$4K |
| D2394 |
|
37 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
219 |
216 |
$2K |
| D2954 |
|
15 |
13 |
$2K |
| D1999 |
|
19 |
18 |
$0.00 |