| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,279 |
4,276 |
$285K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
341 |
287 |
$253K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,586 |
1,289 |
$181K |
| D2750 |
|
177 |
170 |
$159K |
| D2740 |
Crown - porcelain/ceramic |
177 |
86 |
$125K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,300 |
1,094 |
$108K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,323 |
2,320 |
$84K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
635 |
586 |
$83K |
| D0274 |
Bitewings - four radiographic images |
2,253 |
2,253 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,219 |
2,219 |
$76K |
| D0210 |
Intraoral - complete series of radiographic images |
1,879 |
1,869 |
$62K |
| D2331 |
|
414 |
374 |
$52K |
| D2330 |
|
339 |
315 |
$33K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
167 |
91 |
$22K |
| D2332 |
|
167 |
123 |
$21K |
| D0330 |
Panoramic radiographic image |
853 |
853 |
$20K |
| D2335 |
|
99 |
93 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,177 |
1,163 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
974 |
961 |
$16K |
| D5226 |
|
12 |
12 |
$9K |
| D2394 |
|
38 |
26 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
61 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
283 |
282 |
$5K |
| D4342 |
|
19 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
65 |
$891.34 |
| D7311 |
|
13 |
13 |
$60.00 |