| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
629 |
627 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,038 |
1,036 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
174 |
$2K |
| D1110 |
Prophylaxis - adult |
378 |
377 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
556 |
542 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
304 |
179 |
$1K |
| D1206 |
Topical application of fluoride varnish |
824 |
822 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,120 |
1,066 |
$806.00 |
| D0120 |
Periodic oral evaluation - established patient |
258 |
257 |
$280.00 |
| D0274 |
Bitewings - four radiographic images |
294 |
292 |
$232.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
571 |
490 |
$216.00 |
| D0270 |
|
219 |
215 |
$110.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$84.00 |
| D1120 |
Prophylaxis - child |
33 |
33 |
$40.00 |
| D1999 |
|
57 |
54 |
$35.00 |
| D4921 |
|
57 |
27 |
$0.00 |
| D4910 |
|
12 |
12 |
$0.00 |