| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
505 |
$12K |
| D1110 |
Prophylaxis - adult |
676 |
676 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
413 |
413 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
155 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
345 |
345 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
468 |
468 |
$5K |
| D2750 |
|
17 |
14 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
53 |
$3K |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
379 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
340 |
340 |
$1K |
| D2950 |
|
15 |
12 |
$675.00 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$392.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$224.00 |
| D0270 |
|
15 |
15 |
$45.00 |