| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
449 |
449 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
148 |
$13K |
| D0274 |
Bitewings - four radiographic images |
285 |
285 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
76 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
338 |
338 |
$6K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
91 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
47 |
$3K |
| D2332 |
|
53 |
31 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
360 |
349 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
69 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$803.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
75 |
$747.44 |
| D1330 |
|
49 |
49 |
$120.00 |