| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
683 |
678 |
$45K |
| D1110 |
Prophylaxis - adult |
402 |
402 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
258 |
256 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
132 |
132 |
$11K |
| D0330 |
Panoramic radiographic image |
498 |
495 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
129 |
67 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
39 |
$5K |
| D0274 |
Bitewings - four radiographic images |
246 |
246 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
205 |
$3K |
| D4910 |
|
38 |
38 |
$3K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$577.50 |
| D1320 |
|
31 |
31 |
$520.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
121 |
55 |
$473.85 |
| D1330 |
|
24 |
24 |
$0.00 |