| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
625 |
624 |
$33K |
| D4341 |
|
420 |
119 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
565 |
564 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
98 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
94 |
48 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
121 |
121 |
$3K |
| D4910 |
|
32 |
32 |
$2K |
| D1110 |
Prophylaxis - adult |
43 |
42 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
450 |
225 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
111 |
111 |
$987.00 |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$468.00 |
| D9430 |
|
13 |
13 |
$320.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$170.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$130.00 |
| D1330 |
|
31 |
31 |
$0.00 |