| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
551 |
541 |
$19K |
| D0330 |
Panoramic radiographic image |
276 |
274 |
$15K |
| D1110 |
Prophylaxis - adult |
146 |
144 |
$9K |
| D0274 |
Bitewings - four radiographic images |
234 |
234 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
18 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
16 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$825.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$553.19 |
| D1206 |
Topical application of fluoride varnish |
31 |
29 |
$520.35 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$434.00 |
| D9110 |
|
12 |
12 |
$332.73 |