| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,497 |
1,490 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
1,508 |
1,494 |
$82K |
| D0210 |
Intraoral - complete series of radiographic images |
836 |
829 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,839 |
1,628 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
426 |
$26K |
| D0274 |
Bitewings - four radiographic images |
844 |
844 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
83 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
150 |
76 |
$8K |
| D1120 |
Prophylaxis - child |
189 |
188 |
$7K |
| D1206 |
Topical application of fluoride varnish |
194 |
194 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
132 |
$1K |
| D0350 |
|
25 |
13 |
$156.00 |