| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
789 |
783 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
684 |
678 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
89 |
$5K |
| D1206 |
Topical application of fluoride varnish |
219 |
219 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
26 |
$3K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$3K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$691.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
118 |
63 |
$464.25 |