| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
8,401 |
8,401 |
$342K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
729 |
583 |
$291K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,262 |
2,621 |
$221K |
| D0274 |
Bitewings - four radiographic images |
8,160 |
8,160 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
7,554 |
7,554 |
$154K |
| D0220 |
Intraoral - periapical first radiographic image |
9,806 |
9,753 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,491 |
8,475 |
$82K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
770 |
683 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,268 |
2,268 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
999 |
846 |
$43K |
| D2954 |
|
372 |
340 |
$38K |
| D1120 |
Prophylaxis - child |
974 |
974 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
2,699 |
2,663 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,230 |
1,230 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
690 |
683 |
$7K |
| D0330 |
Panoramic radiographic image |
201 |
200 |
$4K |
| D0272 |
Bitewings - two radiographic images |
293 |
293 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
96 |
$3K |
| D2332 |
|
28 |
28 |
$3K |
| D3320 |
|
12 |
12 |
$2K |
| D4341 |
|
30 |
20 |
$2K |
| D9110 |
|
76 |
75 |
$1K |
| D2330 |
|
19 |
13 |
$925.33 |
| D0270 |
|
64 |
64 |
$512.00 |
| D1999 |
|
218 |
203 |
$0.00 |