| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
525 |
520 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
477 |
473 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
253 |
147 |
$17K |
| D9430 |
|
451 |
367 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
162 |
162 |
$12K |
| D0350 |
|
876 |
268 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
56 |
38 |
$7K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$3K |
| D4910 |
|
38 |
38 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
190 |
$3K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$2K |
| D1206 |
Topical application of fluoride varnish |
87 |
86 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
296 |
143 |
$1K |
| D1310 |
|
38 |
38 |
$66.00 |
| D0603 |
|
12 |
12 |
$15.00 |
| D1330 |
|
38 |
37 |
$0.00 |