| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,018 |
1,010 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
2,107 |
2,024 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
680 |
659 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
892 |
887 |
$23K |
| D0274 |
Bitewings - four radiographic images |
594 |
593 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
374 |
$16K |
| D1120 |
Prophylaxis - child |
310 |
308 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
78 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,006 |
949 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
43 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
223 |
$6K |
| D1206 |
Topical application of fluoride varnish |
217 |
215 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
41 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
40 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
16 |
$2K |
| D9110 |
|
17 |
15 |
$621.00 |
| D1999 |
|
80 |
72 |
$0.00 |
| D1330 |
|
14 |
14 |
$0.00 |