| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,439 |
2,421 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,843 |
1,828 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,057 |
1,049 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
620 |
618 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,878 |
2,112 |
$10K |
| D0274 |
Bitewings - four radiographic images |
1,598 |
1,583 |
$10K |
| D9610 |
|
1,254 |
1,176 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
2,136 |
2,111 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
169 |
106 |
$5K |
| D9910 |
|
991 |
991 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
62 |
38 |
$2K |
| D1120 |
Prophylaxis - child |
131 |
131 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
81 |
$1K |
| D1206 |
Topical application of fluoride varnish |
109 |
109 |
$960.00 |
| D2335 |
|
20 |
12 |
$903.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$656.00 |
| D9630 |
|
15 |
14 |
$0.00 |