| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
322 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
218 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
289 |
288 |
$13K |
| D9430 |
|
320 |
291 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
12 |
$4K |
| D1120 |
Prophylaxis - child |
109 |
108 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
706 |
317 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
166 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
39 |
$842.40 |
| D1206 |
Topical application of fluoride varnish |
86 |
86 |
$715.50 |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
34 |
$420.00 |