| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,667 |
1,666 |
$57K |
| D0330 |
Panoramic radiographic image |
660 |
659 |
$34K |
| D1110 |
Prophylaxis - adult |
741 |
741 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
144 |
95 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
564 |
555 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
154 |
153 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
18 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
85 |
$914.44 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$873.21 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$480.09 |