| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
268 |
$17K |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$6K |
| D1120 |
Prophylaxis - child |
117 |
117 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
37 |
$4K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$3K |
| D4910 |
|
26 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
102 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
123 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$585.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$324.00 |