| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
528 |
523 |
$34K |
| D1110 |
Prophylaxis - adult |
315 |
315 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
355 |
246 |
$23K |
| D1120 |
Prophylaxis - child |
425 |
420 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
169 |
169 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
237 |
125 |
$12K |
| D1206 |
Topical application of fluoride varnish |
570 |
570 |
$9K |
| D0274 |
Bitewings - four radiographic images |
431 |
428 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,571 |
768 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
125 |
$6K |
| D9430 |
|
88 |
86 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
35 |
$598.00 |
| D0350 |
|
85 |
42 |
$499.20 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
42 |
$450.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |