| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
359 |
359 |
$23K |
| D1110 |
Prophylaxis - adult |
195 |
195 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
139 |
139 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,345 |
325 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
387 |
387 |
$5K |
| D0350 |
|
486 |
241 |
$5K |
| D0274 |
Bitewings - four radiographic images |
178 |
178 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
29 |
$2K |
| D9430 |
|
66 |
64 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D1999 |
|
33 |
32 |
$0.00 |