| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
339 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
195 |
195 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
244 |
244 |
$12K |
| D1110 |
Prophylaxis - adult |
125 |
125 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
600 |
597 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
54 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
338 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
41 |
$6K |
| D0274 |
Bitewings - four radiographic images |
117 |
117 |
$3K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D9430 |
|
32 |
28 |
$992.00 |