| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,703 |
1,703 |
$107K |
| D1110 |
Prophylaxis - adult |
1,046 |
1,046 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
1,435 |
1,432 |
$85K |
| D1120 |
Prophylaxis - child |
1,747 |
1,743 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
913 |
913 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,073 |
3,066 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
383 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,619 |
2,368 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,674 |
1,673 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
137 |
70 |
$8K |
| D9430 |
|
178 |
178 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
65 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
289 |
289 |
$3K |
| D4341 |
|
47 |
13 |
$3K |
| D4910 |
|
14 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$720.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$312.00 |