| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
145 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
163 |
76 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
37 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$1K |
| D1206 |
Topical application of fluoride varnish |
89 |
83 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$969.08 |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
76 |
$904.32 |
| D0350 |
|
51 |
51 |
$845.48 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$588.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$443.26 |
| D0603 |
|
74 |
74 |
$0.00 |