| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
591 |
588 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
711 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
66 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
67 |
$5K |
| D0330 |
Panoramic radiographic image |
438 |
435 |
$4K |
| D1110 |
Prophylaxis - adult |
380 |
376 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
29 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
145 |
$1K |
| D1120 |
Prophylaxis - child |
79 |
79 |
$754.00 |
| D1330 |
|
150 |
148 |
$650.25 |
| D0140 |
Limited oral evaluation - problem focused |
70 |
68 |
$534.96 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$274.78 |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$260.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$11.90 |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$10.00 |