| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
424 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
319 |
103 |
$17K |
| D1110 |
Prophylaxis - adult |
200 |
200 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
94 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
222 |
221 |
$10K |
| D0350 |
|
844 |
244 |
$7K |
| D4341 |
|
73 |
28 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
218 |
218 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
202 |
50 |
$834.30 |
| D1120 |
Prophylaxis - child |
15 |
14 |
$735.00 |
| D9430 |
|
14 |
14 |
$448.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$237.60 |