| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
687 |
627 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
83 |
27 |
$16K |
| D1110 |
Prophylaxis - adult |
195 |
180 |
$11K |
| D1120 |
Prophylaxis - child |
289 |
261 |
$10K |
| D1351 |
Sealant - per tooth |
310 |
44 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
804 |
374 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
478 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
313 |
295 |
$7K |
| D0274 |
Bitewings - four radiographic images |
203 |
180 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
131 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
25 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
59 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
91 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
71 |
61 |
$2K |
| D0272 |
Bitewings - two radiographic images |
42 |
40 |
$1K |
| D1330 |
|
61 |
60 |
$0.00 |