| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,820 |
415 |
$87K |
| D1110 |
Prophylaxis - adult |
1,254 |
1,098 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
914 |
824 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
1,457 |
1,075 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,481 |
1,267 |
$12K |
| D0330 |
Panoramic radiographic image |
577 |
470 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
595 |
521 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,673 |
722 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,320 |
1,039 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
100 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
29 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
189 |
156 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$422.40 |
| D1330 |
|
122 |
104 |
$0.00 |