| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
437 |
$28K |
| D1110 |
Prophylaxis - adult |
228 |
227 |
$20K |
| D1120 |
Prophylaxis - child |
250 |
247 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
162 |
161 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,339 |
537 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
65 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
392 |
389 |
$5K |
| D4341 |
|
68 |
26 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
29 |
$3K |
| D9430 |
|
66 |
64 |
$2K |
| D0272 |
Bitewings - two radiographic images |
155 |
155 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
12 |
$2K |
| D0350 |
|
94 |
39 |
$835.20 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$410.40 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |