| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
621 |
621 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
551 |
551 |
$26K |
| D1110 |
Prophylaxis - adult |
291 |
291 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
343 |
130 |
$20K |
| D4910 |
|
137 |
137 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
201 |
103 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
99 |
$10K |
| D0350 |
|
974 |
479 |
$9K |
| D9430 |
|
283 |
281 |
$9K |
| D1206 |
Topical application of fluoride varnish |
534 |
533 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,903 |
678 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
155 |
$7K |
| D0330 |
Panoramic radiographic image |
149 |
149 |
$4K |
| D0274 |
Bitewings - four radiographic images |
170 |
170 |
$4K |
| D4341 |
|
37 |
17 |
$3K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$2K |
| D0270 |
|
422 |
406 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
69 |
$828.00 |