| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
431 |
431 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
156 |
156 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
239 |
239 |
$11K |
| D1206 |
Topical application of fluoride varnish |
677 |
670 |
$10K |
| D1120 |
Prophylaxis - child |
201 |
201 |
$8K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$8K |
| D0350 |
|
227 |
210 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
29 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
424 |
194 |
$3K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
82 |
82 |
$1K |