| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,625 |
2,420 |
$88K |
| D1120 |
Prophylaxis - child |
2,567 |
2,407 |
$63K |
| D1351 |
Sealant - per tooth |
2,238 |
458 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
558 |
251 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,491 |
1,459 |
$31K |
| D0330 |
Panoramic radiographic image |
617 |
557 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,293 |
1,172 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,112 |
955 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
70 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
483 |
461 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
62 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
161 |
129 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$994.80 |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$721.84 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$540.76 |