| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
258 |
242 |
$11K |
| D1110 |
Prophylaxis - adult |
256 |
244 |
$9K |
| D0274 |
Bitewings - four radiographic images |
222 |
208 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
25 |
$6K |
| D0330 |
Panoramic radiographic image |
114 |
109 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
360 |
333 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
293 |
257 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
73 |
68 |
$2K |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$251.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$207.48 |