| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
643 |
630 |
$36K |
| D1110 |
Prophylaxis - adult |
784 |
762 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
166 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
747 |
730 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,057 |
1,033 |
$17K |
| D0274 |
Bitewings - four radiographic images |
678 |
660 |
$13K |
| D1120 |
Prophylaxis - child |
633 |
616 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
823 |
803 |
$12K |
| D1351 |
Sealant - per tooth |
463 |
94 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
206 |
201 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
420 |
406 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
74 |
72 |
$720.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
26 |
$180.00 |