| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,048 |
2,042 |
$175K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
360 |
234 |
$166K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,401 |
1,398 |
$89K |
| D4341 |
|
1,049 |
283 |
$71K |
| D0210 |
Intraoral - complete series of radiographic images |
1,473 |
1,468 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
595 |
311 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
564 |
558 |
$34K |
| D1120 |
Prophylaxis - child |
771 |
765 |
$31K |
| D9430 |
|
736 |
733 |
$24K |
| D4910 |
|
295 |
290 |
$22K |
| D0274 |
Bitewings - four radiographic images |
936 |
936 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,616 |
1,859 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,012 |
1,006 |
$13K |
| D2954 |
|
102 |
79 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
105 |
$9K |
| D0350 |
|
1,010 |
417 |
$8K |
| D1320 |
|
442 |
442 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
56 |
40 |
$7K |
| D0330 |
Panoramic radiographic image |
203 |
203 |
$6K |
| D0340 |
|
87 |
87 |
$4K |
| D1206 |
Topical application of fluoride varnish |
205 |
205 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
28 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
145 |
145 |
$2K |
| D9910 |
|
25 |
25 |
$842.80 |
| D0270 |
|
50 |
50 |
$230.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$0.00 |