| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
642 |
$42K |
| D0350 |
|
3,901 |
1,021 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
473 |
472 |
$30K |
| D1120 |
Prophylaxis - child |
472 |
469 |
$19K |
| D9430 |
|
539 |
502 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,171 |
927 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
198 |
110 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
304 |
303 |
$14K |
| D1206 |
Topical application of fluoride varnish |
886 |
881 |
$12K |
| D0274 |
Bitewings - four radiographic images |
399 |
398 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
36 |
$6K |
| D4341 |
|
46 |
13 |
$3K |
| D4910 |
|
27 |
27 |
$2K |
| D1351 |
Sealant - per tooth |
59 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
68 |
$634.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$330.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |