| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
722 |
719 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
417 |
204 |
$28K |
| D1110 |
Prophylaxis - adult |
313 |
311 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
520 |
519 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
269 |
116 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
99 |
99 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
350 |
345 |
$5K |
| D1120 |
Prophylaxis - child |
116 |
110 |
$5K |
| D9430 |
|
166 |
163 |
$5K |
| D1206 |
Topical application of fluoride varnish |
198 |
192 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
24 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
601 |
361 |
$2K |
| D0274 |
Bitewings - four radiographic images |
77 |
71 |
$1K |
| D1310 |
|
13 |
13 |
$506.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$424.00 |
| D0601 |
|
13 |
13 |
$165.00 |