| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$9K |
| D1120 |
Prophylaxis - child |
197 |
196 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
129 |
129 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,001 |
199 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
297 |
295 |
$3K |
| D0274 |
Bitewings - four radiographic images |
106 |
105 |
$2K |
| D0350 |
|
172 |
80 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$900.00 |
| D9430 |
|
14 |
13 |
$448.00 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
30 |
$408.00 |