| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
866 |
865 |
$57K |
| D1110 |
Prophylaxis - adult |
562 |
561 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
483 |
483 |
$37K |
| D1120 |
Prophylaxis - child |
428 |
428 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,186 |
1,185 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
364 |
364 |
$17K |
| D0274 |
Bitewings - four radiographic images |
711 |
710 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
195 |
117 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,898 |
934 |
$12K |
| D0350 |
|
1,095 |
281 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$180.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$133.00 |