| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
408 |
399 |
$27K |
| D1110 |
Prophylaxis - adult |
253 |
253 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
107 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
118 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
588 |
579 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
144 |
144 |
$7K |
| D0330 |
Panoramic radiographic image |
205 |
202 |
$6K |
| D1120 |
Prophylaxis - child |
88 |
84 |
$4K |
| D4341 |
|
50 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
563 |
119 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
14 |
$1K |
| D4910 |
|
15 |
15 |
$1K |
| D9430 |
|
17 |
16 |
$544.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$156.00 |