| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
179 |
179 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
252 |
250 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
51 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
424 |
414 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
265 |
256 |
$7K |
| D1110 |
Prophylaxis - adult |
108 |
104 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
16 |
$3K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D1206 |
Topical application of fluoride varnish |
101 |
101 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
121 |
$2K |
| D0274 |
Bitewings - four radiographic images |
18 |
16 |
$514.40 |