| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,874 |
2,872 |
$115K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
963 |
441 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,835 |
1,835 |
$38K |
| D9310 |
|
509 |
508 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,897 |
2,823 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,270 |
1,270 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
748 |
737 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
919 |
917 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
157 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,666 |
1,651 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
934 |
919 |
$9K |
| D0330 |
Panoramic radiographic image |
141 |
141 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
37 |
$2K |
| D0270 |
|
87 |
87 |
$910.61 |
| D0160 |
|
13 |
13 |
$289.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$56.50 |
| D1999 |
|
268 |
236 |
$0.00 |