| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,897 |
1,893 |
$142K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,072 |
919 |
$138K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,190 |
319 |
$115K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
388 |
271 |
$92K |
| D0210 |
Intraoral - complete series of radiographic images |
572 |
572 |
$68K |
| D0330 |
Panoramic radiographic image |
1,067 |
1,066 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
927 |
921 |
$23K |
| D4910 |
|
165 |
165 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
680 |
409 |
$14K |
| D4341 |
|
209 |
70 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
24 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,052 |
1,051 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,770 |
1,768 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
1,189 |
1,188 |
$1K |
| D2331 |
|
18 |
12 |
$945.67 |
| D0220 |
Intraoral - periapical first radiographic image |
1,613 |
1,593 |
$203.51 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,060 |
1,058 |
$53.63 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,597 |
910 |
$0.00 |