| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
504 |
504 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
321 |
320 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,831 |
963 |
$20K |
| D1120 |
Prophylaxis - child |
408 |
405 |
$15K |
| D0274 |
Bitewings - four radiographic images |
624 |
622 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
26 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
248 |
244 |
$3K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$2K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$2K |
| D1206 |
Topical application of fluoride varnish |
71 |
71 |
$781.50 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D1203 |
|
12 |
12 |
$24.00 |