| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,465 |
1,384 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
531 |
292 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
348 |
202 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,101 |
1,005 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
838 |
783 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,321 |
1,237 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
901 |
852 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,799 |
1,639 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,404 |
879 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
44 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
25 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
30 |
29 |
$920.00 |
| D1999 |
|
84 |
62 |
$0.00 |
| D1330 |
|
924 |
856 |
$0.00 |