| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
596 |
595 |
$35K |
| D1110 |
Prophylaxis - adult |
184 |
184 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
336 |
333 |
$15K |
| D9430 |
|
445 |
395 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
52 |
$9K |
| D2335 |
|
67 |
20 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
41 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
496 |
496 |
$5K |
| D0330 |
Panoramic radiographic image |
222 |
220 |
$5K |
| D0350 |
|
155 |
127 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
91 |
91 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$540.00 |