| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
956 |
950 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
940 |
932 |
$49K |
| D1120 |
Prophylaxis - child |
1,144 |
1,142 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
394 |
384 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,088 |
794 |
$12K |
| D0274 |
Bitewings - four radiographic images |
374 |
374 |
$7K |
| D4341 |
|
93 |
25 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
428 |
426 |
$6K |
| D4910 |
|
70 |
70 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
25 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$2K |
| D9430 |
|
38 |
37 |
$1K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$364.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
17 |
$163.80 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$120.00 |