| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
527 |
496 |
$21K |
| D1110 |
Prophylaxis - adult |
349 |
330 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
96 |
43 |
$16K |
| D0274 |
Bitewings - four radiographic images |
379 |
353 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
59 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
685 |
355 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
550 |
485 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
39 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
136 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
85 |
$3K |
| D1351 |
Sealant - per tooth |
156 |
18 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
149 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$1K |