| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
109 |
103 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
174 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
31 |
$3K |
| D1110 |
Prophylaxis - adult |
82 |
78 |
$2K |
| D0274 |
Bitewings - four radiographic images |
108 |
106 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
102 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$580.00 |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
103 |
$475.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
45 |
$240.00 |
| D1206 |
Topical application of fluoride varnish |
15 |
14 |
$195.00 |