| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
190 |
190 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$5K |
| D1120 |
Prophylaxis - child |
94 |
93 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
105 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
59 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$907.06 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$460.50 |