| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
375 |
373 |
$22K |
| D1206 |
Topical application of fluoride varnish |
151 |
151 |
$4K |
| D0274 |
Bitewings - four radiographic images |
237 |
236 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
16 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
543 |
313 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$2K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$364.00 |