| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
696 |
659 |
$24K |
| D9110 |
|
930 |
874 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
261 |
165 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
158 |
$10K |
| D0274 |
Bitewings - four radiographic images |
460 |
430 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
416 |
396 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
131 |
74 |
$9K |
| D0330 |
Panoramic radiographic image |
244 |
231 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
428 |
399 |
$7K |
| D1120 |
Prophylaxis - child |
157 |
148 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
830 |
795 |
$6K |
| D1206 |
Topical application of fluoride varnish |
258 |
243 |
$3K |
| D2332 |
|
36 |
24 |
$2K |
| D2331 |
|
42 |
26 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
26 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
26 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
233 |
122 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$794.27 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
12 |
$152.55 |
| D9986 |
|
202 |
175 |
$0.00 |
| D9987 |
|
15 |
15 |
$0.00 |