| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
527 |
526 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
191 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
339 |
338 |
$15K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
62 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
55 |
$2K |
| D1120 |
Prophylaxis - child |
83 |
82 |
$2K |
| D2330 |
|
25 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D0350 |
|
60 |
47 |
$1K |
| D0274 |
Bitewings - four radiographic images |
58 |
57 |
$907.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
191 |
111 |
$776.70 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$122.00 |