| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
160 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
46 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
27 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
78 |
$3K |
| D1120 |
Prophylaxis - child |
106 |
103 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
809 |
198 |
$2K |
| D0274 |
Bitewings - four radiographic images |
145 |
142 |
$2K |
| D1110 |
Prophylaxis - adult |
57 |
56 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
95 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
126 |
$993.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$350.00 |