| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
76 |
41 |
$27K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
394 |
215 |
$22K |
| D9310 |
|
391 |
391 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
358 |
136 |
$18K |
| D1110 |
Prophylaxis - adult |
408 |
408 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
91 |
$10K |
| D0274 |
Bitewings - four radiographic images |
414 |
414 |
$8K |
| D2394 |
|
96 |
39 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
391 |
391 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
502 |
501 |
$5K |
| D2954 |
|
46 |
30 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
463 |
463 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
109 |
$737.22 |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$552.16 |