| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
642 |
641 |
$35K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
330 |
121 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
596 |
595 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
123 |
$14K |
| D0274 |
Bitewings - four radiographic images |
477 |
475 |
$11K |
| D2750 |
|
19 |
12 |
$10K |
| D0330 |
Panoramic radiographic image |
264 |
264 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
345 |
345 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
89 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
102 |
102 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
168 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
18 |
$157.97 |