| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
451 |
451 |
$28K |
| D1120 |
Prophylaxis - child |
549 |
548 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
303 |
303 |
$18K |
| D0330 |
Panoramic radiographic image |
446 |
446 |
$13K |
| D1206 |
Topical application of fluoride varnish |
719 |
717 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
143 |
142 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
26 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
540 |
225 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
26 |
$2K |
| D2394 |
|
19 |
16 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$972.00 |
| D9430 |
|
14 |
14 |
$448.00 |
| D0603 |
|
19 |
19 |
$0.00 |
| D1310 |
|
14 |
14 |
$0.00 |
| D9993 |
|
14 |
14 |
$0.00 |