| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
382 |
372 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
131 |
60 |
$8K |
| D1120 |
Prophylaxis - child |
165 |
163 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
160 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
166 |
161 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
156 |
153 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
160 |
$3K |
| D0274 |
Bitewings - four radiographic images |
164 |
160 |
$3K |
| D0330 |
Panoramic radiographic image |
118 |
116 |
$2K |
| D1351 |
Sealant - per tooth |
49 |
18 |
$2K |
| D0272 |
Bitewings - two radiographic images |
205 |
203 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
189 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
83 |
$494.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$330.20 |