| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,103 |
1,094 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
681 |
676 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,188 |
1,659 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
392 |
391 |
$18K |
| D1120 |
Prophylaxis - child |
511 |
509 |
$17K |
| D0274 |
Bitewings - four radiographic images |
741 |
732 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
188 |
92 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
765 |
761 |
$9K |
| D9430 |
|
181 |
180 |
$6K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
13 |
$4K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
26 |
13 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
25 |
$2K |
| D9222 |
|
13 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |
| D1206 |
Topical application of fluoride varnish |
26 |
25 |
$186.00 |