| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
871 |
870 |
$31K |
| D1120 |
Prophylaxis - child |
679 |
677 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,071 |
1,069 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,333 |
1,318 |
$15K |
| D0274 |
Bitewings - four radiographic images |
446 |
443 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,279 |
1,141 |
$12K |
| D1351 |
Sealant - per tooth |
367 |
84 |
$9K |
| D1110 |
Prophylaxis - adult |
193 |
192 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
641 |
334 |
$6K |
| D0272 |
Bitewings - two radiographic images |
253 |
253 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
33 |
14 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
28 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
114 |
113 |
$2K |
| D0330 |
Panoramic radiographic image |
89 |
89 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$787.02 |