| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
183 |
$4K |
| D1110 |
Prophylaxis - adult |
61 |
60 |
$2K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
15 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
30 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$342.55 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$311.85 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
45 |
$195.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
13 |
$165.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
14 |
$75.00 |