| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
360 |
359 |
$24K |
| D9430 |
|
727 |
663 |
$23K |
| D1110 |
Prophylaxis - adult |
239 |
238 |
$21K |
| D4910 |
|
243 |
243 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
73 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
223 |
223 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
130 |
130 |
$10K |
| D0350 |
|
937 |
243 |
$8K |
| D1206 |
Topical application of fluoride varnish |
301 |
300 |
$5K |
| D0274 |
Bitewings - four radiographic images |
249 |
249 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
958 |
480 |
$4K |
| D4341 |
|
40 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
44 |
$540.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$472.50 |
| D1320 |
|
12 |
12 |
$210.00 |