| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
18 |
18 |
$810.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$585.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
97 |
$485.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$325.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
64 |
$285.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$192.00 |