| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,551 |
1,550 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,211 |
555 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
1,077 |
1,075 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
875 |
871 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,968 |
1,553 |
$33K |
| D1110 |
Prophylaxis - adult |
333 |
333 |
$29K |
| D1120 |
Prophylaxis - child |
619 |
616 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
306 |
208 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
152 |
101 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,012 |
1,010 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
779 |
779 |
$11K |
| D1206 |
Topical application of fluoride varnish |
279 |
277 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
147 |
$2K |