| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
324 |
308 |
$22K |
| D0330 |
Panoramic radiographic image |
180 |
180 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
457 |
264 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
63 |
$15K |
| D1206 |
Topical application of fluoride varnish |
325 |
316 |
$13K |
| D0274 |
Bitewings - four radiographic images |
208 |
208 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
356 |
344 |
$8K |
| D1120 |
Prophylaxis - child |
171 |
171 |
$7K |
| D1110 |
Prophylaxis - adult |
95 |
95 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
41 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
58 |
$5K |
| D0272 |
Bitewings - two radiographic images |
99 |
99 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
67 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$318.00 |