| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
338 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$8K |
| D1110 |
Prophylaxis - adult |
96 |
96 |
$8K |
| D1206 |
Topical application of fluoride varnish |
490 |
488 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
42 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,112 |
241 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$1K |
| D4910 |
|
13 |
13 |
$924.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$105.00 |