| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,133 |
2,103 |
$114K |
| D0274 |
Bitewings - four radiographic images |
1,974 |
1,948 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,501 |
2,465 |
$61K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
138 |
56 |
$57K |
| D1120 |
Prophylaxis - child |
945 |
934 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,529 |
1,514 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
496 |
295 |
$41K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
238 |
58 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
441 |
437 |
$18K |
| D0330 |
Panoramic radiographic image |
301 |
295 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
411 |
402 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
115 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
53 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
347 |
337 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |