| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,190 |
1,190 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
543 |
542 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,303 |
1,409 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,087 |
1,086 |
$23K |
| D1110 |
Prophylaxis - adult |
231 |
231 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
251 |
251 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
102 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
147 |
75 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
55 |
$5K |
| D1120 |
Prophylaxis - child |
121 |
121 |
$4K |
| D4341 |
|
40 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
124 |
$2K |
| D0350 |
|
132 |
61 |
$1K |
| D9430 |
|
25 |
25 |
$800.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
98 |
$777.00 |