| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
973 |
963 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
360 |
230 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
663 |
661 |
$22K |
| D1110 |
Prophylaxis - adult |
616 |
613 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
485 |
478 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
665 |
657 |
$11K |
| D1120 |
Prophylaxis - child |
174 |
174 |
$7K |
| D4341 |
|
44 |
16 |
$6K |
| D1206 |
Topical application of fluoride varnish |
208 |
208 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
491 |
488 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
29 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
548 |
420 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |