| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
784 |
780 |
$20K |
| D1110 |
Prophylaxis - adult |
408 |
407 |
$14K |
| D0274 |
Bitewings - four radiographic images |
539 |
536 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
90 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,242 |
538 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
101 |
68 |
$5K |
| D2160 |
|
65 |
43 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
230 |
$4K |
| D0330 |
Panoramic radiographic image |
80 |
77 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
721 |
708 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
37 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
28 |
$3K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$3K |
| D1206 |
Topical application of fluoride varnish |
162 |
162 |
$2K |
| D2140 |
|
43 |
28 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
29 |
$677.08 |