| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
839 |
778 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
800 |
714 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
90 |
16 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
495 |
460 |
$9K |
| D0274 |
Bitewings - four radiographic images |
218 |
191 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
709 |
605 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
127 |
121 |
$912.99 |
| D0330 |
Panoramic radiographic image |
16 |
13 |
$677.48 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$454.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
25 |
$349.00 |