| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
424 |
424 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
65 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
148 |
73 |
$20K |
| D1110 |
Prophylaxis - adult |
174 |
174 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
58 |
$11K |
| D1351 |
Sealant - per tooth |
164 |
21 |
$7K |
| D0274 |
Bitewings - four radiographic images |
265 |
265 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
233 |
233 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
390 |
390 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
16 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
35 |
27 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
344 |
344 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
64 |
$3K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$2K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$475.89 |
| D0270 |
|
13 |
13 |
$117.00 |