| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,808 |
1,808 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
1,665 |
1,663 |
$44K |
| D0274 |
Bitewings - four radiographic images |
742 |
741 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
131 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
386 |
384 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
119 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
318 |
318 |
$9K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
12 |
$2K |
| D9110 |
|
59 |
59 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
59 |
$777.63 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$494.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$305.98 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$149.10 |