| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,893 |
5,893 |
$272K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,564 |
2,112 |
$252K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
321 |
238 |
$146K |
| D0210 |
Intraoral - complete series of radiographic images |
2,798 |
2,786 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
3,665 |
3,665 |
$84K |
| D7240 |
Removal of impacted tooth - completely bony |
328 |
255 |
$83K |
| D0274 |
Bitewings - four radiographic images |
3,660 |
3,660 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,972 |
1,181 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,223 |
3,223 |
$77K |
| D2791 |
|
144 |
126 |
$73K |
| D0220 |
Intraoral - periapical first radiographic image |
4,582 |
4,560 |
$50K |
| D2954 |
|
449 |
363 |
$47K |
| D4341 |
|
748 |
331 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
440 |
364 |
$34K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
292 |
260 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,766 |
3,766 |
$20K |
| D1320 |
|
1,084 |
1,084 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
560 |
551 |
$7K |
| D3320 |
|
16 |
12 |
$6K |
| D9944 |
|
24 |
24 |
$2K |
| D2331 |
|
16 |
12 |
$1K |
| D2330 |
|
21 |
12 |
$835.56 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$787.52 |