| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
167 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
19 |
$1K |
| D0274 |
Bitewings - four radiographic images |
102 |
74 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
57 |
$1K |
| D1110 |
Prophylaxis - adult |
43 |
40 |
$878.84 |
| D1120 |
Prophylaxis - child |
44 |
40 |
$720.06 |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
92 |
$692.04 |
| D1206 |
Topical application of fluoride varnish |
55 |
49 |
$566.16 |
| D0330 |
Panoramic radiographic image |
109 |
89 |
$502.35 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
12 |
$76.82 |
| D0350 |
|
12 |
12 |
$47.44 |
| D1999 |
|
403 |
279 |
$0.00 |
| D9215 |
|
168 |
126 |
$0.00 |