| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
3,766 |
906 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
461 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,345 |
800 |
$18K |
| D1120 |
Prophylaxis - child |
272 |
272 |
$14K |
| D0274 |
Bitewings - four radiographic images |
371 |
371 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
52 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
423 |
423 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
500 |
423 |
$6K |
| D1351 |
Sealant - per tooth |
155 |
47 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
68 |
$6K |
| D9430 |
|
56 |
54 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
15 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$312.00 |