| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,702 |
2,408 |
$101K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,747 |
1,165 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,894 |
3,451 |
$92K |
| D0330 |
Panoramic radiographic image |
2,533 |
2,222 |
$82K |
| D0274 |
Bitewings - four radiographic images |
2,971 |
2,615 |
$63K |
| D1120 |
Prophylaxis - child |
1,255 |
1,112 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
965 |
545 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,064 |
503 |
$39K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
890 |
468 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
436 |
249 |
$33K |
| D5110 |
|
41 |
41 |
$26K |
| D5120 |
|
38 |
38 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,289 |
1,155 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,811 |
2,327 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
621 |
545 |
$13K |
| D1206 |
Topical application of fluoride varnish |
1,057 |
918 |
$12K |
| D2750 |
|
20 |
13 |
$12K |
| D2140 |
|
201 |
105 |
$7K |
| D9110 |
|
304 |
249 |
$5K |
| D2160 |
|
83 |
50 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
962 |
556 |
$4K |
| D2950 |
|
40 |
29 |
$4K |
| D2331 |
|
90 |
48 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
38 |
$3K |
| D2335 |
|
23 |
12 |
$1K |
| D2332 |
|
18 |
12 |
$1K |
| D0431 |
|
121 |
113 |
$970.00 |
| D2161 |
|
19 |
12 |
$923.64 |
| D1320 |
|
96 |
86 |
$660.00 |
| D9986 |
|
215 |
200 |
$603.00 |
| D2330 |
|
27 |
15 |
$483.12 |
| D1321 |
|
34 |
32 |
$448.50 |
| D9987 |
|
98 |
91 |
$288.00 |