| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,720 |
2,719 |
$108K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
609 |
322 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
3,955 |
3,811 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,543 |
2,505 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,707 |
1,707 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
2,161 |
2,136 |
$35K |
| D9310 |
|
359 |
358 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
779 |
779 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
133 |
$14K |
| D0330 |
Panoramic radiographic image |
237 |
237 |
$7K |
| D0274 |
Bitewings - four radiographic images |
353 |
353 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
576 |
573 |
$6K |
| D2394 |
|
38 |
24 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$758.78 |
| D0160 |
|
26 |
26 |
$645.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$266.10 |
| D1999 |
|
667 |
562 |
$0.00 |