| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
151 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
14 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
27 |
14 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
114 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
40 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
144 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$444.44 |
| D0270 |
|
15 |
15 |
$196.95 |