| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,808 |
1,709 |
$45K |
| D1110 |
Prophylaxis - adult |
1,127 |
1,057 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
510 |
229 |
$29K |
| D1120 |
Prophylaxis - child |
328 |
328 |
$17K |
| D0274 |
Bitewings - four radiographic images |
656 |
633 |
$15K |
| D0330 |
Panoramic radiographic image |
428 |
418 |
$13K |
| D2394 |
|
178 |
74 |
$11K |
| D1206 |
Topical application of fluoride varnish |
754 |
731 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
128 |
61 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
417 |
392 |
$3K |
| D4341 |
|
44 |
19 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
171 |
86 |
$938.15 |
| D9110 |
|
48 |
45 |
$935.55 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$751.18 |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$570.00 |
| D9986 |
|
1,260 |
1,056 |
$0.00 |
| D9987 |
|
144 |
116 |
$0.00 |
| D1999 |
|
137 |
128 |
$0.00 |