| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
218 |
218 |
$18K |
| D9430 |
|
539 |
470 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
199 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
80 |
$11K |
| D1110 |
Prophylaxis - adult |
118 |
118 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
169 |
$8K |
| D1206 |
Topical application of fluoride varnish |
475 |
475 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,804 |
409 |
$7K |
| D0274 |
Bitewings - four radiographic images |
336 |
336 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
49 |
$7K |
| D0350 |
|
627 |
188 |
$6K |
| D4910 |
|
13 |
13 |
$924.00 |
| D9910 |
|
15 |
15 |
$903.00 |