| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
296 |
222 |
$13K |
| D4342 |
|
137 |
44 |
$13K |
| D0274 |
Bitewings - four radiographic images |
289 |
218 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
172 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
26 |
$9K |
| D0330 |
Panoramic radiographic image |
160 |
119 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
216 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
14 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
12 |
$5K |
| D4910 |
|
43 |
24 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
54 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
177 |
$2K |
| D2950 |
|
15 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
29 |
$2K |