| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
385 |
381 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
248 |
247 |
$11K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
172 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
416 |
415 |
$5K |
| D9430 |
|
109 |
108 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
602 |
274 |
$2K |
| D0274 |
Bitewings - four radiographic images |
80 |
80 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$836.80 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
25 |
$324.00 |