| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
324 |
323 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
476 |
476 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
111 |
$11K |
| D0274 |
Bitewings - four radiographic images |
262 |
262 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
62 |
$5K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
54 |
$3K |
| T1015 |
Clinic visit/encounter, all-inclusive |
12 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
202 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
83 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
16 |
$1K |
| D1120 |
Prophylaxis - child |
33 |
33 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
60 |
$881.57 |
| D2330 |
|
15 |
14 |
$817.80 |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$672.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$238.00 |