| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
276 |
171 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
211 |
$2K |
| D1110 |
Prophylaxis - adult |
170 |
164 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
216 |
$916.74 |
| D0274 |
Bitewings - four radiographic images |
109 |
103 |
$668.23 |
| D1206 |
Topical application of fluoride varnish |
183 |
179 |
$489.50 |
| D0220 |
Intraoral - periapical first radiographic image |
177 |
162 |
$437.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
116 |
$390.00 |
| D1120 |
Prophylaxis - child |
61 |
59 |
$310.50 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$111.24 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$0.00 |