| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D5750 |
|
733 |
730 |
$143K |
| D5751 |
|
609 |
609 |
$119K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,672 |
1,669 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
1,359 |
1,344 |
$102K |
| D1110 |
Prophylaxis - adult |
1,103 |
1,092 |
$98K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
664 |
250 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
625 |
619 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
334 |
211 |
$22K |
| D1206 |
Topical application of fluoride varnish |
827 |
815 |
$14K |
| D9430 |
|
423 |
423 |
$14K |
| D4910 |
|
121 |
121 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
112 |
80 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,455 |
331 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
285 |
$3K |
| D5850 |
|
15 |
15 |
$1K |
| D5851 |
|
12 |
12 |
$840.00 |