| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
958 |
955 |
$79K |
| D4341 |
|
807 |
233 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,133 |
1,133 |
$48K |
| D4910 |
|
518 |
518 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
620 |
617 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
375 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,218 |
908 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,590 |
1,587 |
$18K |
| D1120 |
Prophylaxis - child |
383 |
383 |
$11K |
| D0274 |
Bitewings - four radiographic images |
448 |
448 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
138 |
82 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
288 |
$3K |
| D0350 |
|
290 |
171 |
$3K |
| D2140 |
|
20 |
12 |
$1K |