| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
1,426 |
367 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,126 |
375 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
111 |
$7K |
| D1110 |
Prophylaxis - adult |
73 |
73 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
29 |
$6K |
| D4910 |
|
58 |
58 |
$4K |
| D9430 |
|
121 |
110 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
81 |
$4K |
| D1206 |
Topical application of fluoride varnish |
228 |
227 |
$4K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
18 |
17 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$787.50 |