| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
494 |
493 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
314 |
78 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
293 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
343 |
343 |
$15K |
| D1120 |
Prophylaxis - child |
332 |
329 |
$13K |
| D1206 |
Topical application of fluoride varnish |
722 |
719 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,107 |
556 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
26 |
$5K |
| D4910 |
|
70 |
69 |
$5K |
| D0274 |
Bitewings - four radiographic images |
246 |
242 |
$5K |
| D2330 |
|
50 |
12 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$118.00 |