| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
55 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
32 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
55 |
$920.00 |
| D1110 |
Prophylaxis - adult |
24 |
18 |
$688.00 |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
66 |
$679.00 |
| D1120 |
Prophylaxis - child |
19 |
16 |
$624.00 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
13 |
$351.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
12 |
$264.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
13 |
$98.00 |