| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,793 |
4,711 |
$252K |
| D2740 |
Crown - porcelain/ceramic |
165 |
125 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
4,650 |
4,568 |
$108K |
| D0274 |
Bitewings - four radiographic images |
2,547 |
2,502 |
$90K |
| D0220 |
Intraoral - periapical first radiographic image |
5,560 |
5,383 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,277 |
606 |
$81K |
| D0140 |
Limited oral evaluation - problem focused |
1,929 |
1,892 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
778 |
469 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
768 |
759 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,031 |
3,517 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,252 |
1,224 |
$52K |
| D1120 |
Prophylaxis - child |
928 |
904 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,627 |
1,597 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
191 |
121 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
12 |
$10K |
| D0272 |
Bitewings - two radiographic images |
210 |
205 |
$6K |
| D9110 |
|
151 |
148 |
$5K |
| D2950 |
|
18 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
50 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D1999 |
|
31 |
24 |
$0.00 |