| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
745 |
740 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
513 |
510 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,791 |
809 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
329 |
329 |
$14K |
| D1110 |
Prophylaxis - adult |
94 |
94 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
52 |
$8K |
| D0272 |
Bitewings - two radiographic images |
603 |
600 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
436 |
433 |
$6K |
| D1120 |
Prophylaxis - child |
109 |
109 |
$4K |
| D4341 |
|
36 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
71 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$842.40 |
| D0350 |
|
57 |
31 |
$825.60 |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$360.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |