| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
217 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
170 |
$5K |
| D1120 |
Prophylaxis - child |
119 |
119 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
39 |
$4K |
| D1110 |
Prophylaxis - adult |
77 |
76 |
$4K |
| D0274 |
Bitewings - four radiographic images |
208 |
204 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
115 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
223 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
153 |
$734.72 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$606.60 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$569.05 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$497.12 |