| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,229 |
1,228 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
594 |
593 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
436 |
235 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
944 |
943 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
728 |
727 |
$12K |
| D0274 |
Bitewings - four radiographic images |
467 |
467 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,257 |
1,241 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,001 |
998 |
$5K |
| D0272 |
Bitewings - two radiographic images |
320 |
320 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
85 |
85 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
65 |
$969.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$350.00 |
| D9310 |
|
15 |
15 |
$300.00 |