| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
805 |
796 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
649 |
640 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
200 |
196 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
45 |
$7K |
| D4341 |
|
96 |
27 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
383 |
368 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
258 |
137 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$720.00 |