| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,084 |
2,053 |
$69K |
| D2752 |
|
125 |
97 |
$58K |
| D8670 |
Periodic orthodontic treatment visit |
570 |
539 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
2,329 |
2,295 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,189 |
1,150 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
3,481 |
3,408 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,853 |
1,823 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
939 |
933 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
501 |
496 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,567 |
2,891 |
$15K |
| D2954 |
|
178 |
137 |
$15K |
| D1120 |
Prophylaxis - child |
420 |
415 |
$9K |
| D1206 |
Topical application of fluoride varnish |
424 |
419 |
$6K |
| D9310 |
|
159 |
154 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
91 |
86 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$836.00 |
| D0270 |
|
83 |
82 |
$117.00 |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
12 |
$0.00 |