| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
112 |
106 |
$9K |
| D1110 |
Prophylaxis - adult |
212 |
207 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
33 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
192 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
285 |
268 |
$6K |
| D0274 |
Bitewings - four radiographic images |
178 |
168 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
272 |
256 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
42 |
$1K |