| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
822 |
821 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
404 |
404 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
348 |
348 |
$15K |
| D1120 |
Prophylaxis - child |
507 |
503 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
102 |
$11K |
| D1110 |
Prophylaxis - adult |
104 |
102 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
45 |
26 |
$5K |
| D0274 |
Bitewings - four radiographic images |
236 |
235 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
51 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,022 |
552 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
185 |
$2K |
| D9430 |
|
13 |
13 |
$416.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$304.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |