| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
774 |
722 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
783 |
724 |
$9K |
| D1120 |
Prophylaxis - child |
397 |
384 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
159 |
80 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
810 |
743 |
$7K |
| D1110 |
Prophylaxis - adult |
349 |
321 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
211 |
206 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
349 |
325 |
$6K |
| D0274 |
Bitewings - four radiographic images |
353 |
328 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
222 |
198 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
601 |
540 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
72 |
$3K |
| D0272 |
Bitewings - two radiographic images |
160 |
151 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
25 |
$664.95 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
14 |
$0.00 |
| D1351 |
Sealant - per tooth |
55 |
13 |
$0.00 |