| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,285 |
2,275 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
3,650 |
3,645 |
$82K |
| D0140 |
Limited oral evaluation - problem focused |
1,692 |
1,672 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
4,501 |
4,446 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,203 |
1,196 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,541 |
1,540 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
181 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,469 |
2,453 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
283 |
280 |
$18K |
| D4342 |
|
179 |
73 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
40 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
85 |
49 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$6K |
| D2950 |
|
30 |
24 |
$4K |
| D4341 |
|
33 |
12 |
$4K |
| D1206 |
Topical application of fluoride varnish |
131 |
131 |
$2K |
| D4910 |
|
25 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$774.86 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$391.53 |