| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
304 |
304 |
$20K |
| D1110 |
Prophylaxis - adult |
204 |
203 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
185 |
185 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
509 |
504 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
43 |
$5K |
| D4910 |
|
54 |
54 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$4K |
| D4341 |
|
38 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
419 |
253 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D0350 |
|
88 |
26 |
$758.40 |
| D9430 |
|
14 |
12 |
$448.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |