| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
583 |
426 |
$207K |
| D1110 |
Prophylaxis - adult |
4,362 |
4,358 |
$151K |
| D2954 |
|
1,536 |
1,274 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
5,766 |
5,760 |
$111K |
| D0274 |
Bitewings - four radiographic images |
5,337 |
5,337 |
$100K |
| D0220 |
Intraoral - periapical first radiographic image |
6,635 |
6,608 |
$60K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
123 |
114 |
$35K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
641 |
559 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,211 |
6,196 |
$29K |
| D2791 |
|
82 |
74 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
616 |
461 |
$24K |
| D2140 |
|
550 |
486 |
$23K |
| D2330 |
|
481 |
404 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
372 |
370 |
$7K |
| D1120 |
Prophylaxis - child |
189 |
189 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
971 |
960 |
$5K |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
55 |
$2K |
| D4341 |
|
45 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
141 |
$1K |
| D2160 |
|
12 |
12 |
$695.70 |
| D2920 |
|
16 |
13 |
$438.60 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$278.00 |
| D9110 |
|
26 |
26 |
$249.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$222.50 |
| D1203 |
|
34 |
34 |
$0.00 |