| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
217 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
31 |
$6K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
152 |
$2K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$741.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
59 |
$703.32 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
13 |
$642.32 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$587.56 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$477.73 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$463.40 |