| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0250 |
|
2,899 |
555 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
830 |
820 |
$54K |
| D1110 |
Prophylaxis - adult |
461 |
453 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
357 |
352 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
67 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
39 |
$6K |
| D1206 |
Topical application of fluoride varnish |
322 |
313 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
76 |
76 |
$5K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
192 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
208 |
111 |
$847.47 |
| D0350 |
|
314 |
71 |
$556.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$182.00 |