| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
482 |
443 |
$23K |
| D1110 |
Prophylaxis - adult |
634 |
579 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
379 |
245 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
725 |
668 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
279 |
252 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
110 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
118 |
91 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
265 |
242 |
$5K |
| D1120 |
Prophylaxis - child |
91 |
85 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
476 |
434 |
$3K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$2K |
| D0274 |
Bitewings - four radiographic images |
101 |
80 |
$2K |
| D1206 |
Topical application of fluoride varnish |
164 |
150 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
15 |
$184.20 |