| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
676 |
675 |
$44K |
| D1110 |
Prophylaxis - adult |
326 |
325 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
252 |
252 |
$21K |
| D4910 |
|
269 |
269 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
332 |
332 |
$16K |
| D1206 |
Topical application of fluoride varnish |
935 |
934 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,996 |
641 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
84 |
$11K |
| D9430 |
|
297 |
272 |
$10K |
| D0350 |
|
761 |
288 |
$7K |
| D4341 |
|
86 |
24 |
$6K |
| D1120 |
Prophylaxis - child |
109 |
109 |
$5K |
| D0272 |
Bitewings - two radiographic images |
319 |
319 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
170 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |