| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
733 |
728 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
672 |
668 |
$32K |
| D9430 |
|
193 |
142 |
$6K |
| D1320 |
|
128 |
128 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$870.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
24 |
$324.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
28 |
$311.85 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$180.00 |
| D1330 |
|
128 |
128 |
$0.00 |