| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
406 |
352 |
$9K |
| D1120 |
Prophylaxis - child |
183 |
168 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
50 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
42 |
$5K |
| D4341 |
|
22 |
14 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
147 |
145 |
$4K |
| D0274 |
Bitewings - four radiographic images |
264 |
227 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
134 |
$4K |
| D1110 |
Prophylaxis - adult |
81 |
79 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
261 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
92 |
$2K |
| D0330 |
Panoramic radiographic image |
88 |
85 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
59 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
246 |
219 |
$1K |
| D8670 |
Periodic orthodontic treatment visit |
13 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
48 |
46 |
$816.20 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$812.00 |