| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
84 |
84 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
16 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$950.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
184 |
183 |
$828.75 |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$650.88 |
| D1330 |
|
185 |
185 |
$610.64 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$226.05 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$143.65 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$78.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$49.42 |