| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,514 |
1,514 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
1,016 |
1,010 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,493 |
2,803 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
886 |
886 |
$42K |
| D1110 |
Prophylaxis - adult |
451 |
451 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
504 |
311 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,310 |
2,301 |
$33K |
| D9430 |
|
981 |
945 |
$31K |
| D1120 |
Prophylaxis - child |
684 |
684 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,034 |
1,029 |
$21K |
| D2740 |
Crown - porcelain/ceramic |
41 |
31 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
224 |
110 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
226 |
128 |
$12K |
| D0350 |
|
894 |
365 |
$8K |
| D4910 |
|
97 |
97 |
$7K |
| D4341 |
|
64 |
17 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
343 |
337 |
$4K |
| D2140 |
|
71 |
39 |
$4K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$225.00 |