| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,591 |
1,583 |
$98K |
| D9430 |
|
1,728 |
1,554 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
1,130 |
1,128 |
$51K |
| D1110 |
Prophylaxis - adult |
500 |
498 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
299 |
132 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
80 |
$12K |
| D1206 |
Topical application of fluoride varnish |
608 |
608 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
84 |
40 |
$10K |
| D0274 |
Bitewings - four radiographic images |
469 |
469 |
$10K |
| D0350 |
|
1,087 |
278 |
$10K |
| D4341 |
|
91 |
24 |
$6K |
| D2330 |
|
65 |
24 |
$5K |
| D1320 |
|
97 |
96 |
$2K |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$660.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
69 |
$563.85 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
14 |
$105.00 |