| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
309 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
349 |
135 |
$19K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
89 |
$11K |
| D4910 |
|
118 |
118 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
171 |
$8K |
| D0350 |
|
755 |
228 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
360 |
360 |
$5K |
| D1120 |
Prophylaxis - child |
91 |
91 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,062 |
238 |
$5K |
| D4341 |
|
48 |
12 |
$3K |
| D9430 |
|
58 |
55 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
65 |
$780.00 |