| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
32 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
45 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
22 |
19 |
$378.25 |
| D0274 |
Bitewings - four radiographic images |
18 |
13 |
$372.80 |
| D1120 |
Prophylaxis - child |
15 |
12 |
$345.00 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
16 |
$87.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
14 |
$46.00 |