| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
701 |
692 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
837 |
825 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
66 |
$3K |
| D1110 |
Prophylaxis - adult |
252 |
250 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
154 |
66 |
$1K |
| D1120 |
Prophylaxis - child |
22 |
21 |
$1K |
| D0274 |
Bitewings - four radiographic images |
140 |
136 |
$296.81 |
| D0120 |
Periodic oral evaluation - established patient |
33 |
31 |
$260.00 |
| D0220 |
Intraoral - periapical first radiographic image |
177 |
171 |
$215.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
174 |
$106.06 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$0.00 |