| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,404 |
1,393 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
1,611 |
1,608 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,196 |
1,173 |
$52K |
| D1120 |
Prophylaxis - child |
1,063 |
1,054 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,003 |
1,959 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,183 |
1,177 |
$24K |
| D4910 |
|
178 |
178 |
$14K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
51 |
24 |
$5K |
| D4341 |
|
87 |
24 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
72 |
38 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
25 |
$2K |
| D9430 |
|
49 |
48 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$940.80 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$312.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
14 |
$114.00 |