| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
588 |
588 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
262 |
262 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
90 |
$10K |
| D1120 |
Prophylaxis - child |
321 |
320 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
79 |
41 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,841 |
435 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
496 |
456 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
479 |
478 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
30 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0350 |
|
185 |
100 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$1K |