| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,441 |
1,440 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,258 |
1,257 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
258 |
126 |
$18K |
| D0272 |
Bitewings - two radiographic images |
793 |
793 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
89 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
40 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
107 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
103 |
$765.91 |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$659.18 |