| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
803 |
802 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
567 |
565 |
$27K |
| D1120 |
Prophylaxis - child |
131 |
131 |
$6K |
| D4910 |
|
70 |
70 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
208 |
208 |
$3K |
| D9430 |
|
57 |
55 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
278 |
108 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$669.60 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$364.00 |