| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,014 |
2,005 |
$128K |
| D1110 |
Prophylaxis - adult |
1,021 |
1,016 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
1,279 |
1,270 |
$85K |
| D0210 |
Intraoral - complete series of radiographic images |
1,397 |
1,397 |
$67K |
| D1120 |
Prophylaxis - child |
1,766 |
1,753 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
525 |
260 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,891 |
2,875 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,573 |
1,563 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
450 |
200 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,348 |
2,196 |
$21K |
| D4910 |
|
230 |
230 |
$18K |
| D9430 |
|
288 |
278 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
19 |
12 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$995.50 |