| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
413 |
412 |
$20K |
| D4910 |
|
122 |
122 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
999 |
377 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
582 |
582 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
116 |
$6K |
| D1120 |
Prophylaxis - child |
115 |
115 |
$3K |
| D0274 |
Bitewings - four radiographic images |
161 |
159 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
38 |
$2K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$2K |
| D0350 |
|
34 |
26 |
$439.20 |