| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
151 |
$5K |
| D0274 |
Bitewings - four radiographic images |
164 |
150 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
194 |
179 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
190 |
$2K |
| D1120 |
Prophylaxis - child |
82 |
69 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
49 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
133 |
$1K |
| D1110 |
Prophylaxis - adult |
33 |
29 |
$969.66 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
13 |
$693.80 |
| D0120 |
Periodic oral evaluation - established patient |
56 |
44 |
$498.53 |