| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
648 |
644 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
487 |
487 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
108 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
88 |
$7K |
| D1120 |
Prophylaxis - child |
135 |
135 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
36 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
633 |
254 |
$3K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$1K |
| D9430 |
|
17 |
16 |
$512.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$162.00 |
| D0350 |
|
16 |
13 |
$153.60 |