| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
290 |
277 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
50 |
$10K |
| D1110 |
Prophylaxis - adult |
218 |
206 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
32 |
$7K |
| D1120 |
Prophylaxis - child |
167 |
167 |
$7K |
| D1206 |
Topical application of fluoride varnish |
204 |
203 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
187 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
261 |
253 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
58 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
188 |
126 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$432.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$321.00 |