| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,145 |
1,145 |
$52K |
| D0330 |
Panoramic radiographic image |
756 |
756 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
960 |
958 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
337 |
208 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,140 |
1,140 |
$28K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
175 |
114 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
948 |
948 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
282 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
739 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
60 |
$7K |
| D1206 |
Topical application of fluoride varnish |
397 |
397 |
$6K |
| D1120 |
Prophylaxis - child |
65 |
65 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$265.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
16 |
$185.10 |