| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,391 |
1,389 |
$48K |
| D0274 |
Bitewings - four radiographic images |
881 |
881 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
653 |
653 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
231 |
92 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
156 |
57 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
485 |
483 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
69 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
398 |
365 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
530 |
529 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
156 |
156 |
$3K |
| D7240 |
Removal of impacted tooth - completely bony |
15 |
12 |
$3K |
| D9310 |
|
31 |
31 |
$1K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$759.24 |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$404.43 |