| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
894 |
894 |
$58K |
| D1110 |
Prophylaxis - adult |
569 |
569 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
445 |
443 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
515 |
515 |
$24K |
| D1120 |
Prophylaxis - child |
452 |
452 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,084 |
785 |
$16K |
| D4910 |
|
185 |
185 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
107 |
$14K |
| D1206 |
Topical application of fluoride varnish |
680 |
680 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
651 |
650 |
$9K |
| D9430 |
|
258 |
236 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
46 |
$6K |
| D0274 |
Bitewings - four radiographic images |
226 |
226 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
209 |
$3K |
| D0330 |
Panoramic radiographic image |
122 |
122 |
$2K |
| D0350 |
|
189 |
67 |
$2K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$276.00 |