| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,164 |
3,163 |
$171K |
| D0274 |
Bitewings - four radiographic images |
2,910 |
2,907 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,296 |
2,291 |
$66K |
| D2394 |
|
384 |
291 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,994 |
1,994 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
576 |
447 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
435 |
361 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
720 |
445 |
$43K |
| D0330 |
Panoramic radiographic image |
1,062 |
1,059 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
1,088 |
1,085 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,181 |
1,166 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
925 |
884 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
87 |
67 |
$7K |
| D1120 |
Prophylaxis - child |
170 |
170 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
49 |
$3K |
| D1206 |
Topical application of fluoride varnish |
90 |
90 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
104 |
$1K |
| D9110 |
|
35 |
33 |
$885.95 |
| D7311 |
|
13 |
13 |
$81.84 |
| D1999 |
|
1,167 |
1,023 |
$0.00 |