| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
382 |
371 |
$16K |
| D2750 |
|
46 |
38 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
100 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
499 |
410 |
$5K |
| D2954 |
|
68 |
60 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
114 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
27 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
14 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
81 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
83 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$467.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
50 |
$277.10 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$227.66 |