| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
228 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
52 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
26 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
349 |
120 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
28 |
26 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
12 |
$900.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
50 |
$521.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$312.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
13 |
$180.00 |