| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2752 |
|
325 |
246 |
$145K |
| D1110 |
Prophylaxis - adult |
2,900 |
2,900 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
4,043 |
4,040 |
$79K |
| D0330 |
Panoramic radiographic image |
2,101 |
2,101 |
$54K |
| D0272 |
Bitewings - two radiographic images |
1,638 |
1,638 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,950 |
1,907 |
$18K |
| D0160 |
|
648 |
648 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
677 |
677 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
331 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
63 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
50 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
56 |
$3K |
| D2954 |
|
32 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
120 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$527.38 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$57.75 |