| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,355 |
5,349 |
$200K |
| D0120 |
Periodic oral evaluation - established patient |
7,112 |
7,100 |
$144K |
| D0274 |
Bitewings - four radiographic images |
5,627 |
5,625 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,647 |
1,096 |
$101K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,883 |
926 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
7,626 |
7,478 |
$73K |
| D1120 |
Prophylaxis - child |
1,233 |
1,232 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,636 |
2,633 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,501 |
5,491 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
1,554 |
1,542 |
$15K |
| D0330 |
Panoramic radiographic image |
325 |
325 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
14 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
78 |
$4K |
| D2954 |
|
34 |
24 |
$3K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$417.94 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$324.08 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$221.80 |