| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,053 |
844 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
268 |
146 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
593 |
458 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
70 |
$17K |
| D1110 |
Prophylaxis - adult |
414 |
365 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
312 |
296 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
295 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
150 |
$4K |
| D0330 |
Panoramic radiographic image |
21 |
19 |
$1K |
| D1120 |
Prophylaxis - child |
41 |
28 |
$569.14 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$422.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$174.22 |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
12 |
$172.92 |