| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
663 |
585 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
817 |
716 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
236 |
126 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
257 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
120 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
64 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
93 |
$3K |
| D0274 |
Bitewings - four radiographic images |
123 |
114 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
322 |
$2K |
| D2331 |
|
33 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$94.26 |