| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
257 |
253 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
331 |
$7K |
| D1110 |
Prophylaxis - adult |
189 |
189 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
255 |
254 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
26 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$1K |
| D1120 |
Prophylaxis - child |
35 |
35 |
$620.00 |
| D0274 |
Bitewings - four radiographic images |
27 |
25 |
$436.00 |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
85 |
$411.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
15 |
$219.25 |
| D0350 |
|
56 |
56 |
$147.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
14 |
$105.00 |