| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
263 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
99 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
74 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,909 |
456 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
196 |
194 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
141 |
$6K |
| D1120 |
Prophylaxis - child |
169 |
167 |
$5K |
| D0350 |
|
482 |
215 |
$4K |
| D0274 |
Bitewings - four radiographic images |
161 |
157 |
$3K |
| D1206 |
Topical application of fluoride varnish |
243 |
235 |
$2K |
| D2954 |
|
22 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
180 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
135 |
135 |
$1K |
| D9430 |
|
46 |
39 |
$1K |
| D4910 |
|
13 |
13 |
$924.00 |
| D1110 |
Prophylaxis - adult |
17 |
16 |
$600.00 |