| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
3,887 |
987 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
350 |
349 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
257 |
256 |
$12K |
| D1110 |
Prophylaxis - adult |
90 |
90 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,608 |
292 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
488 |
487 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
25 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$777.60 |
| D9430 |
|
13 |
12 |
$384.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |