| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
465 |
465 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
323 |
$25K |
| D1110 |
Prophylaxis - adult |
284 |
283 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
314 |
314 |
$15K |
| D4910 |
|
165 |
165 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
890 |
881 |
$12K |
| D9430 |
|
375 |
292 |
$12K |
| D0350 |
|
829 |
301 |
$8K |
| D0330 |
Panoramic radiographic image |
198 |
198 |
$6K |
| D1120 |
Prophylaxis - child |
106 |
106 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
36 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
25 |
$4K |
| D1320 |
|
242 |
242 |
$4K |
| D4341 |
|
50 |
14 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
808 |
406 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
249 |
199 |
$3K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$1K |