| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,291 |
973 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
792 |
633 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
952 |
769 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
375 |
207 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,215 |
899 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
361 |
191 |
$22K |
| D0274 |
Bitewings - four radiographic images |
641 |
479 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
55 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
50 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
79 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
61 |
$796.07 |