| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,290 |
1,290 |
$85K |
| D1110 |
Prophylaxis - adult |
826 |
826 |
$72K |
| D4910 |
|
741 |
741 |
$57K |
| D4341 |
|
715 |
190 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
900 |
900 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
515 |
515 |
$39K |
| D1120 |
Prophylaxis - child |
731 |
731 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,688 |
1,688 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
139 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
98 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,228 |
1,083 |
$13K |
| D0274 |
Bitewings - four radiographic images |
574 |
572 |
$12K |
| D1351 |
Sealant - per tooth |
166 |
36 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
516 |
496 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
12 |
$3K |
| D9430 |
|
69 |
66 |
$2K |
| D0350 |
|
142 |
49 |
$1K |
| D0272 |
Bitewings - two radiographic images |
94 |
94 |
$1K |
| D1310 |
|
12 |
12 |
$552.00 |