| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
500 |
493 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
388 |
383 |
$18K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
42 |
42 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
110 |
$1K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$885.60 |
| D1120 |
Prophylaxis - child |
39 |
39 |
$750.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
42 |
$339.46 |
| D1310 |
|
16 |
16 |
$0.00 |
| D9910 |
|
71 |
30 |
$0.00 |