| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
288 |
278 |
$7K |
| D1110 |
Prophylaxis - adult |
133 |
130 |
$5K |
| D0274 |
Bitewings - four radiographic images |
196 |
192 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
27 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
357 |
330 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
68 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
418 |
291 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
60 |
60 |
$2K |
| D1206 |
Topical application of fluoride varnish |
106 |
102 |
$1K |
| D1120 |
Prophylaxis - child |
73 |
69 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$899.92 |
| D1351 |
Sealant - per tooth |
183 |
17 |
$675.05 |
| D0272 |
Bitewings - two radiographic images |
15 |
14 |
$49.62 |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
12 |
$0.00 |