| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
184 |
182 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
27 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
136 |
$4K |
| D1120 |
Prophylaxis - child |
169 |
168 |
$2K |
| D1110 |
Prophylaxis - adult |
65 |
64 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
240 |
$535.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
325 |
323 |
$478.71 |
| D1330 |
|
291 |
289 |
$66.00 |
| D0272 |
Bitewings - two radiographic images |
147 |
146 |
$23.38 |
| D0230 |
Intraoral - periapical each additional radiographic image |
214 |
213 |
$0.00 |