| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
490 |
490 |
$20K |
| D1110 |
Prophylaxis - adult |
350 |
350 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
61 |
$11K |
| D0274 |
Bitewings - four radiographic images |
323 |
323 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
353 |
351 |
$5K |
| D1206 |
Topical application of fluoride varnish |
238 |
238 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
241 |
217 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
45 |
45 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$950.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$514.30 |