| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
202 |
171 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
154 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
79 |
$2K |
| D1120 |
Prophylaxis - child |
61 |
54 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
400 |
109 |
$2K |
| D0330 |
Panoramic radiographic image |
120 |
89 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
115 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
13 |
$947.10 |
| D1206 |
Topical application of fluoride varnish |
36 |
28 |
$875.00 |
| D0120 |
Periodic oral evaluation - established patient |
64 |
58 |
$661.25 |
| D0274 |
Bitewings - four radiographic images |
54 |
45 |
$609.08 |
| D1110 |
Prophylaxis - adult |
37 |
24 |
$528.00 |
| D4355 |
|
31 |
16 |
$420.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$133.12 |