| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
109 |
107 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
143 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
116 |
113 |
$2K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D0350 |
|
117 |
116 |
$1K |
| D1120 |
Prophylaxis - child |
58 |
56 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
67 |
$970.00 |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
79 |
$452.80 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$306.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
13 |
$230.20 |