| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
213 |
207 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
222 |
216 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
59 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$1K |
| D1999 |
|
20 |
16 |
$886.47 |
| D0120 |
Periodic oral evaluation - established patient |
24 |
24 |
$531.05 |
| D4355 |
|
14 |
14 |
$472.72 |
| D0251 |
|
202 |
196 |
$118.59 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$32.00 |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$10.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
46 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |