| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
148 |
$5K |
| D9243 |
|
79 |
28 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
135 |
133 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
40 |
12 |
$4K |
| D9239 |
|
26 |
26 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$976.85 |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$837.41 |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
71 |
$793.59 |
| D9610 |
|
27 |
27 |
$704.08 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$364.79 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$316.05 |