| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
150 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
42 |
$7K |
| D1120 |
Prophylaxis - child |
121 |
107 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
228 |
203 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
63 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
69 |
28 |
$4K |
| D1110 |
Prophylaxis - adult |
118 |
100 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
27 |
$3K |
| D0274 |
Bitewings - four radiographic images |
89 |
82 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
64 |
58 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
34 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
16 |
$247.38 |