| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
3,095 |
680 |
$28K |
| D9430 |
|
456 |
406 |
$14K |
| D4910 |
|
93 |
92 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$6K |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$5K |
| D1206 |
Topical application of fluoride varnish |
274 |
271 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
879 |
330 |
$4K |
| D1320 |
|
212 |
212 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
12 |
$2K |
| D0270 |
|
102 |
100 |
$510.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |