| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,467 |
3,464 |
$180K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,342 |
739 |
$119K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,702 |
2,702 |
$79K |
| D0274 |
Bitewings - four radiographic images |
2,497 |
2,494 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
1,197 |
1,197 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,817 |
1,811 |
$47K |
| D0330 |
Panoramic radiographic image |
1,171 |
1,166 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
564 |
207 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
203 |
137 |
$22K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
14 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
63 |
$5K |
| D1120 |
Prophylaxis - child |
79 |
79 |
$3K |
| D2954 |
|
15 |
15 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
78 |
$1K |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$744.99 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$210.00 |
| D1330 |
|
595 |
595 |
$0.00 |
| D1999 |
|
13 |
12 |
$0.00 |