| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
561 |
561 |
$37K |
| D1110 |
Prophylaxis - adult |
413 |
413 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
262 |
105 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
329 |
327 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
179 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
198 |
69 |
$11K |
| D9430 |
|
325 |
293 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
671 |
670 |
$9K |
| D0330 |
Panoramic radiographic image |
378 |
378 |
$6K |
| D0350 |
|
73 |
66 |
$2K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D1320 |
|
32 |
32 |
$535.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
15 |
$174.15 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$166.00 |