| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
556 |
541 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
359 |
347 |
$15K |
| D0350 |
|
1,238 |
331 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
67 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
517 |
235 |
$2K |
| D0274 |
Bitewings - four radiographic images |
105 |
96 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
46 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$710.00 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
13 |
$126.00 |
| D9430 |
|
15 |
14 |
$105.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$102.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$35.00 |
| D4050 |
|
16 |
16 |
$0.00 |