| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
772 |
769 |
$49K |
| D1110 |
Prophylaxis - adult |
296 |
295 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
541 |
538 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
378 |
371 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,232 |
1,218 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
99 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
82 |
$10K |
| D2791 |
|
16 |
12 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,055 |
500 |
$4K |
| D0274 |
Bitewings - four radiographic images |
148 |
148 |
$3K |
| D1120 |
Prophylaxis - child |
71 |
65 |
$3K |
| D0350 |
|
87 |
26 |
$940.80 |