| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
546 |
542 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
426 |
203 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
338 |
173 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
420 |
418 |
$20K |
| D1110 |
Prophylaxis - adult |
170 |
168 |
$15K |
| D1120 |
Prophylaxis - child |
215 |
213 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
497 |
492 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,114 |
234 |
$5K |
| D0350 |
|
422 |
135 |
$4K |
| D9430 |
|
72 |
71 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$1K |
| D4910 |
|
13 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
41 |
$525.00 |