| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
216 |
215 |
$9K |
| D1110 |
Prophylaxis - adult |
413 |
411 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
289 |
286 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
219 |
218 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
266 |
$2K |
| D1330 |
|
485 |
482 |
$1K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
227 |
$289.59 |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
168 |
$185.19 |