| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
4,123 |
1,063 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
530 |
524 |
$24K |
| D1110 |
Prophylaxis - adult |
271 |
268 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
356 |
356 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,600 |
737 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
293 |
$13K |
| D0274 |
Bitewings - four radiographic images |
523 |
517 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
502 |
501 |
$6K |
| D1120 |
Prophylaxis - child |
174 |
174 |
$5K |
| D9430 |
|
104 |
101 |
$3K |
| D1206 |
Topical application of fluoride varnish |
96 |
93 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$928.20 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
25 |
$312.00 |