| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,864 |
4,845 |
$105K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
219 |
184 |
$98K |
| D0210 |
Intraoral - complete series of radiographic images |
2,944 |
2,939 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,503 |
3,488 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,952 |
2,940 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,029 |
648 |
$47K |
| D0274 |
Bitewings - four radiographic images |
2,736 |
2,722 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
5,592 |
5,359 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,156 |
3,829 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
305 |
173 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
543 |
534 |
$12K |
| D1120 |
Prophylaxis - child |
408 |
408 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
129 |
75 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
124 |
88 |
$6K |
| D2954 |
|
67 |
58 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
343 |
343 |
$4K |
| D0330 |
Panoramic radiographic image |
210 |
209 |
$2K |
| D4341 |
|
35 |
12 |
$2K |
| D2950 |
|
31 |
25 |
$1K |
| D9310 |
|
70 |
70 |
$1K |
| D2332 |
|
18 |
12 |
$931.50 |
| D0603 |
|
12 |
12 |
$120.00 |
| D8670 |
Periodic orthodontic treatment visit |
460 |
458 |
$0.00 |
| D1330 |
|
28 |
28 |
$0.00 |
| D1999 |
|
3,049 |
2,562 |
$0.00 |