| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$4K |
| D1206 |
Topical application of fluoride varnish |
88 |
88 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
12 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$1K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$576.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
62 |
$261.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$128.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$124.20 |