| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
406 |
398 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
309 |
307 |
$14K |
| D9430 |
|
252 |
220 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
39 |
39 |
$3K |
| D1110 |
Prophylaxis - adult |
47 |
44 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
499 |
238 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
96 |
93 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
109 |
$1K |
| D4910 |
|
12 |
12 |
$924.00 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
61 |
$605.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$302.40 |
| D1330 |
|
265 |
261 |
$0.00 |