| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
535 |
$35K |
| D0350 |
|
1,715 |
427 |
$16K |
| D1110 |
Prophylaxis - adult |
160 |
160 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
123 |
122 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$9K |
| D1206 |
Topical application of fluoride varnish |
578 |
578 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
48 |
$4K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$820.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
86 |
$696.60 |