| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,703 |
1,701 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,407 |
704 |
$92K |
| D1120 |
Prophylaxis - child |
1,324 |
1,322 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
1,142 |
1,140 |
$54K |
| D0350 |
|
6,090 |
1,577 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
461 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,899 |
1,894 |
$34K |
| D1110 |
Prophylaxis - adult |
354 |
354 |
$30K |
| D1351 |
Sealant - per tooth |
778 |
185 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
540 |
281 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
242 |
144 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
196 |
73 |
$11K |
| D1310 |
|
253 |
252 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,837 |
951 |
$7K |
| D1320 |
|
399 |
397 |
$7K |
| D0274 |
Bitewings - four radiographic images |
347 |
347 |
$6K |
| D4341 |
|
36 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
131 |
131 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
113 |
$1K |
| D0603 |
|
93 |
92 |
$1K |
| D0602 |
|
14 |
14 |
$210.00 |