| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
545 |
509 |
$23K |
| D1110 |
Prophylaxis - adult |
225 |
214 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
704 |
649 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
56 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
143 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
196 |
188 |
$447.62 |
| D1330 |
|
195 |
190 |
$124.39 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$94.06 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |