| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
294 |
294 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,405 |
445 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
179 |
$10K |
| D1120 |
Prophylaxis - child |
176 |
174 |
$5K |
| D1206 |
Topical application of fluoride varnish |
334 |
334 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$4K |
| D4910 |
|
43 |
43 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
27 |
$3K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |