| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
451 |
447 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
562 |
560 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
600 |
596 |
$27K |
| D0350 |
|
1,190 |
642 |
$15K |
| D4341 |
|
213 |
63 |
$14K |
| D9110 |
|
243 |
236 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
542 |
540 |
$10K |
| D9430 |
|
257 |
227 |
$8K |
| D9910 |
|
109 |
107 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
27 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
722 |
368 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
47 |
47 |
$2K |
| D2332 |
|
23 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
105 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$182.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$158.00 |