| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$7K |
| D1110 |
Prophylaxis - adult |
101 |
101 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
24 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
324 |
305 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
123 |
123 |
$3K |
| D0274 |
Bitewings - four radiographic images |
87 |
86 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
200 |
167 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$360.00 |