| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
210 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
27 |
13 |
$5K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$4K |
| D1351 |
Sealant - per tooth |
106 |
16 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
38 |
$3K |
| D1110 |
Prophylaxis - adult |
41 |
40 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
50 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
106 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
62 |
$1K |
| D1206 |
Topical application of fluoride varnish |
36 |
35 |
$855.57 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$463.40 |