| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,458 |
2,456 |
$120K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
797 |
384 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,183 |
2,181 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
761 |
660 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,450 |
1,447 |
$31K |
| D0330 |
Panoramic radiographic image |
769 |
767 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
752 |
751 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
257 |
216 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
845 |
839 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,016 |
993 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
67 |
$6K |
| D1120 |
Prophylaxis - child |
64 |
64 |
$3K |
| D2331 |
|
17 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$308.32 |