| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
260 |
87 |
$68K |
| D1110 |
Prophylaxis - adult |
1,844 |
1,843 |
$54K |
| D9310 |
|
640 |
640 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
628 |
358 |
$18K |
| D0274 |
Bitewings - four radiographic images |
905 |
905 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
895 |
895 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
804 |
804 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,762 |
1,735 |
$14K |
| D0330 |
Panoramic radiographic image |
581 |
581 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
277 |
205 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
676 |
670 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
91 |
32 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,176 |
1,176 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
25 |
$2K |
| D9110 |
|
92 |
86 |
$1K |
| D4341 |
|
31 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
55 |
$877.82 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$870.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$475.85 |
| D0270 |
|
12 |
12 |
$100.53 |
| D1999 |
|
63 |
53 |
$0.00 |