| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
397 |
397 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
300 |
300 |
$14K |
| D1110 |
Prophylaxis - adult |
143 |
143 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
72 |
$7K |
| D4341 |
|
80 |
24 |
$6K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
40 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
145 |
$2K |
| D0350 |
|
236 |
98 |
$2K |
| D2331 |
|
22 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
211 |
70 |
$857.11 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$282.60 |