| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
636 |
630 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
661 |
661 |
$44K |
| D1110 |
Prophylaxis - adult |
342 |
342 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
355 |
180 |
$23K |
| D9430 |
|
679 |
647 |
$22K |
| D1120 |
Prophylaxis - child |
349 |
349 |
$15K |
| D0330 |
Panoramic radiographic image |
454 |
454 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
918 |
911 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
568 |
528 |
$7K |
| D4910 |
|
26 |
26 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$864.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
205 |
136 |
$826.20 |