| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
156 |
153 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
147 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
144 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
30 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
12 |
$1K |
| D9110 |
|
28 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
165 |
$1K |
| D0274 |
Bitewings - four radiographic images |
102 |
100 |
$930.51 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
31 |
$789.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$368.21 |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
49 |
$168.21 |