| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,058 |
1,057 |
$70K |
| D0210 |
Intraoral - complete series of radiographic images |
866 |
865 |
$41K |
| D1110 |
Prophylaxis - adult |
236 |
236 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
45 |
$8K |
| D4341 |
|
108 |
28 |
$8K |
| D9430 |
|
144 |
138 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
304 |
304 |
$4K |
| D0350 |
|
321 |
80 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
628 |
183 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$2K |
| D1320 |
|
98 |
98 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
114 |
$1K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$226.00 |