| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
456 |
344 |
$204K |
| D4342 |
|
661 |
247 |
$61K |
| D1110 |
Prophylaxis - adult |
1,275 |
1,261 |
$55K |
| D0330 |
Panoramic radiographic image |
811 |
810 |
$41K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
284 |
151 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,052 |
1,047 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
153 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
201 |
133 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,059 |
1,052 |
$31K |
| D2950 |
|
243 |
203 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,208 |
1,192 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
304 |
92 |
$27K |
| D4910 |
|
298 |
287 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
619 |
605 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
219 |
218 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
714 |
700 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
24 |
$5K |
| D2394 |
|
14 |
13 |
$3K |
| D2332 |
|
16 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
60 |
$872.71 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$360.24 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$358.59 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$228.32 |