| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
360 |
355 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
127 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
432 |
$17K |
| D1110 |
Prophylaxis - adult |
253 |
252 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
15 |
13 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
174 |
174 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
186 |
184 |
$3K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$948.08 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$793.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
68 |
$695.18 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$528.09 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$517.90 |