| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
484 |
484 |
$31K |
| D1110 |
Prophylaxis - adult |
265 |
265 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,015 |
1,013 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
101 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
275 |
275 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,896 |
317 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
55 |
35 |
$7K |
| D1120 |
Prophylaxis - child |
159 |
159 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
48 |
$4K |
| D0350 |
|
321 |
135 |
$4K |
| D0274 |
Bitewings - four radiographic images |
136 |
136 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
19 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |