| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,020 |
1,019 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
325 |
313 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
436 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
62 |
30 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
40 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
197 |
196 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
248 |
246 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
94 |
$910.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$905.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
54 |
$756.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$516.00 |
| D9110 |
|
13 |
12 |
$246.02 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$182.00 |