| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D5110 |
|
217 |
212 |
$153K |
| D5120 |
|
134 |
129 |
$95K |
| D0330 |
Panoramic radiographic image |
2,627 |
2,069 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,597 |
2,014 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
3,019 |
2,373 |
$39K |
| D5212 |
|
84 |
84 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,921 |
2,210 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
1,072 |
740 |
$15K |
| D1110 |
Prophylaxis - adult |
409 |
396 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,483 |
721 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
114 |
53 |
$9K |
| D5211 |
|
25 |
25 |
$6K |
| D0274 |
Bitewings - four radiographic images |
287 |
281 |
$5K |
| D0272 |
Bitewings - two radiographic images |
280 |
246 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
182 |
167 |
$3K |
| D0170 |
|
71 |
71 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$804.48 |
| D4346 |
|
12 |
12 |
$566.28 |
| D9630 |
|
26 |
25 |
$278.18 |
| D1206 |
Topical application of fluoride varnish |
13 |
12 |
$228.69 |
| D4341 |
|
56 |
16 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$0.00 |
| D2950 |
|
35 |
25 |
$0.00 |
| D4355 |
|
28 |
28 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
25 |
$0.00 |