| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,301 |
1,301 |
$70K |
| D0274 |
Bitewings - four radiographic images |
884 |
884 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
647 |
647 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
653 |
653 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,463 |
1,457 |
$12K |
| D0330 |
Panoramic radiographic image |
272 |
272 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
359 |
359 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,096 |
1,093 |
$7K |
| D2750 |
|
15 |
13 |
$6K |
| D9310 |
|
82 |
82 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
40 |
24 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
60 |
$840.00 |