| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
445 |
445 |
$27K |
| D1120 |
Prophylaxis - child |
590 |
589 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,275 |
1,270 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
300 |
$16K |
| D9430 |
|
427 |
417 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
120 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
179 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,448 |
728 |
$6K |
| D0350 |
|
610 |
319 |
$6K |
| D0274 |
Bitewings - four radiographic images |
193 |
193 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
29 |
$3K |
| D4910 |
|
12 |
12 |
$924.00 |
| D1310 |
|
13 |
13 |
$552.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$180.00 |