| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,728 |
2,724 |
$177K |
| D1110 |
Prophylaxis - adult |
1,855 |
1,853 |
$154K |
| D0210 |
Intraoral - complete series of radiographic images |
1,986 |
1,980 |
$90K |
| D1120 |
Prophylaxis - child |
1,160 |
1,152 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
686 |
686 |
$54K |
| D1351 |
Sealant - per tooth |
1,313 |
237 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,047 |
3,030 |
$44K |
| D9430 |
|
1,354 |
1,210 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,659 |
1,166 |
$23K |
| D0274 |
Bitewings - four radiographic images |
844 |
839 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
72 |
37 |
$8K |
| D0330 |
Panoramic radiographic image |
192 |
192 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
17 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
126 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$336.00 |
| D0350 |
|
26 |
12 |
$211.20 |