| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,717 |
2,514 |
$106K |
| D0330 |
Panoramic radiographic image |
2,454 |
2,293 |
$85K |
| D2750 |
|
184 |
101 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,869 |
2,695 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,890 |
2,710 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,647 |
1,509 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
498 |
342 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
330 |
228 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,021 |
1,792 |
$11K |
| D1120 |
Prophylaxis - child |
130 |
127 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
110 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
25 |
$3K |
| D2394 |
|
44 |
37 |
$2K |
| D0160 |
|
30 |
30 |
$2K |
| D2950 |
|
16 |
12 |
$2K |
| D2332 |
|
22 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$799.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$354.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
37 |
$318.39 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$225.26 |
| D9986 |
|
1,191 |
1,025 |
$0.00 |