| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
841 |
840 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,899 |
1,476 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
214 |
$13K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
66 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
92 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
65 |
$816.00 |
| D9430 |
|
14 |
13 |
$448.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$300.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$100.00 |