| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,236 |
1,236 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,243 |
1,243 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
918 |
498 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
1,094 |
1,090 |
$52K |
| D1120 |
Prophylaxis - child |
827 |
827 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,295 |
1,667 |
$34K |
| D1110 |
Prophylaxis - adult |
343 |
343 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
545 |
273 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,943 |
1,941 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,107 |
1,107 |
$23K |
| D4910 |
|
186 |
186 |
$13K |
| D4341 |
|
180 |
49 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,040 |
928 |
$12K |
| D0350 |
|
1,179 |
417 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
83 |
41 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D9430 |
|
14 |
14 |
$448.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$192.00 |