| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,752 |
1,742 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
1,874 |
1,869 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
962 |
369 |
$64K |
| D1120 |
Prophylaxis - child |
1,487 |
1,479 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,255 |
2,628 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
1,092 |
1,086 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,146 |
1,140 |
$24K |
| D1110 |
Prophylaxis - adult |
188 |
183 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,309 |
1,306 |
$15K |
| D9430 |
|
221 |
221 |
$7K |
| D1351 |
Sealant - per tooth |
276 |
64 |
$7K |
| D4910 |
|
77 |
77 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
32 |
13 |
$4K |
| D0272 |
Bitewings - two radiographic images |
301 |
301 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
24 |
$2K |
| D1206 |
Topical application of fluoride varnish |
195 |
192 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |