| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,354 |
1,354 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
673 |
433 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,011 |
1,011 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
847 |
847 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
815 |
815 |
$15K |
| D0330 |
Panoramic radiographic image |
442 |
442 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
347 |
228 |
$15K |
| D9110 |
|
410 |
396 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
126 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
73 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
914 |
879 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
431 |
408 |
$4K |
| D1206 |
Topical application of fluoride varnish |
223 |
223 |
$4K |
| D1120 |
Prophylaxis - child |
170 |
170 |
$4K |
| D2332 |
|
38 |
25 |
$2K |
| D0601 |
|
169 |
169 |
$2K |
| D1330 |
|
313 |
313 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$1K |
| D1320 |
|
88 |
82 |
$1K |
| D2330 |
|
16 |
12 |
$708.36 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$681.30 |
| D0602 |
|
12 |
12 |
$120.00 |
| D0603 |
|
12 |
12 |
$120.00 |