| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
958 |
950 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,008 |
1,008 |
$17K |
| D1110 |
Prophylaxis - adult |
2,027 |
2,025 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,011 |
776 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
995 |
706 |
$11K |
| D1206 |
Topical application of fluoride varnish |
2,470 |
2,469 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
659 |
650 |
$6K |
| D4341 |
|
156 |
79 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,222 |
1,220 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,654 |
1,628 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
1,355 |
1,353 |
$3K |
| D4342 |
|
100 |
56 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,164 |
934 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
133 |
124 |
$2K |
| D4910 |
|
341 |
341 |
$2K |
| D0270 |
|
346 |
343 |
$891.00 |
| D1120 |
Prophylaxis - child |
83 |
83 |
$840.00 |
| D0603 |
|
238 |
238 |
$737.00 |
| D0330 |
Panoramic radiographic image |
225 |
222 |
$520.00 |
| D1330 |
|
3,225 |
3,120 |
$241.32 |
| D1310 |
|
2,472 |
2,400 |
$60.00 |
| D0602 |
|
13 |
13 |
$44.00 |
| D4921 |
|
249 |
117 |
$0.00 |