| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
481 |
480 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
200 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
56 |
$8K |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$3K |
| D1120 |
Prophylaxis - child |
83 |
83 |
$3K |
| D1206 |
Topical application of fluoride varnish |
116 |
115 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$638.23 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$605.88 |