| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
9,439 |
9,431 |
$436K |
| D0274 |
Bitewings - four radiographic images |
9,990 |
9,988 |
$220K |
| D0120 |
Periodic oral evaluation - established patient |
6,023 |
6,017 |
$140K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,202 |
1,567 |
$132K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,447 |
1,538 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,375 |
4,374 |
$105K |
| D0210 |
Intraoral - complete series of radiographic images |
4,003 |
3,996 |
$95K |
| D0220 |
Intraoral - periapical first radiographic image |
6,625 |
6,616 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,980 |
5,979 |
$64K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
68 |
65 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
353 |
304 |
$19K |
| D9110 |
|
344 |
343 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
49 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
408 |
408 |
$5K |
| D2330 |
|
68 |
52 |
$3K |
| D2331 |
|
43 |
38 |
$3K |
| D4341 |
|
62 |
25 |
$3K |
| D2954 |
|
12 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$860.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$410.88 |