| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,728 |
1,728 |
$106K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
325 |
239 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
484 |
367 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
468 |
468 |
$34K |
| D1120 |
Prophylaxis - child |
696 |
696 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
693 |
693 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
881 |
881 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
192 |
166 |
$23K |
| D0274 |
Bitewings - four radiographic images |
535 |
535 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
56 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
71 |
$16K |
| D0330 |
Panoramic radiographic image |
229 |
229 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
857 |
857 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
272 |
272 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
592 |
591 |
$9K |
| D2332 |
|
51 |
45 |
$7K |
| D0272 |
Bitewings - two radiographic images |
186 |
186 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
44 |
$750.50 |
| D0270 |
|
14 |
14 |
$162.00 |