| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
170 |
$10K |
| D1110 |
Prophylaxis - adult |
122 |
122 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
119 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
237 |
237 |
$5K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$5K |
| D1120 |
Prophylaxis - child |
116 |
116 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
306 |
297 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
31 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
263 |
212 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
102 |
102 |
$3K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$808.34 |