| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,208 |
1,208 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
911 |
903 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
717 |
353 |
$48K |
| D1120 |
Prophylaxis - child |
887 |
880 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
866 |
866 |
$39K |
| D0350 |
|
2,372 |
800 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,960 |
1,157 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,733 |
1,725 |
$21K |
| D0274 |
Bitewings - four radiographic images |
601 |
596 |
$12K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
42 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
33 |
13 |
$4K |
| D9430 |
|
26 |
25 |
$832.00 |