| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
783 |
781 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
633 |
632 |
$30K |
| D1110 |
Prophylaxis - adult |
247 |
247 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
115 |
$14K |
| D9430 |
|
228 |
225 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
63 |
27 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
51 |
$6K |
| D0330 |
Panoramic radiographic image |
184 |
184 |
$5K |
| D1206 |
Topical application of fluoride varnish |
269 |
269 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
51 |
51 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
334 |
153 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
28 |
$1K |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$1K |