| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
492 |
492 |
$32K |
| D1110 |
Prophylaxis - adult |
346 |
344 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
408 |
$29K |
| D9430 |
|
517 |
428 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,023 |
1,020 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
253 |
253 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,620 |
727 |
$6K |
| D0274 |
Bitewings - four radiographic images |
277 |
275 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
39 |
$5K |
| D1120 |
Prophylaxis - child |
120 |
119 |
$5K |
| D4910 |
|
13 |
13 |
$1K |
| D0350 |
|
95 |
28 |
$825.60 |