| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
736 |
731 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
373 |
261 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
177 |
119 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
316 |
253 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
77 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
330 |
330 |
$11K |
| D0274 |
Bitewings - four radiographic images |
372 |
367 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
540 |
535 |
$9K |
| D0330 |
Panoramic radiographic image |
155 |
155 |
$7K |
| D2950 |
|
52 |
46 |
$7K |
| D9630 |
|
386 |
383 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
140 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
305 |
300 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
24 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
112 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
161 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D4910 |
|
13 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
21 |
21 |
$915.18 |
| D9994 |
|
237 |
236 |
$0.00 |