| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
770 |
732 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
201 |
71 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
311 |
121 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
342 |
332 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
841 |
789 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
335 |
303 |
$9K |
| D1110 |
Prophylaxis - adult |
203 |
200 |
$8K |
| D0274 |
Bitewings - four radiographic images |
265 |
258 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
271 |
263 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
28 |
$5K |
| D1351 |
Sealant - per tooth |
207 |
27 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
449 |
338 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
145 |
$3K |
| D1120 |
Prophylaxis - child |
73 |
70 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
16 |
12 |
$231.10 |