| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
451 |
446 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
360 |
355 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
397 |
394 |
$8K |
| D1120 |
Prophylaxis - child |
276 |
275 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
87 |
$5K |
| D0274 |
Bitewings - four radiographic images |
322 |
319 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,052 |
608 |
$3K |
| D1206 |
Topical application of fluoride varnish |
282 |
279 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$546.00 |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
227 |
$462.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$42.00 |