| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
375 |
372 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
130 |
$9K |
| D1110 |
Prophylaxis - adult |
326 |
325 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
386 |
384 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
269 |
264 |
$4K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$402.04 |
| D0120 |
Periodic oral evaluation - established patient |
117 |
116 |
$178.91 |
| D0274 |
Bitewings - four radiographic images |
117 |
116 |
$71.00 |
| D9110 |
|
155 |
151 |
$37.00 |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
207 |
$18.95 |
| D1330 |
|
430 |
426 |
$3.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |