| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,823 |
1,815 |
$82K |
| D0330 |
Panoramic radiographic image |
1,558 |
1,549 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
483 |
297 |
$64K |
| D0140 |
Limited oral evaluation - problem focused |
1,786 |
1,715 |
$63K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
336 |
213 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,111 |
1,096 |
$44K |
| D2740 |
Crown - porcelain/ceramic |
78 |
56 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,386 |
1,381 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,545 |
1,544 |
$37K |
| D0350 |
|
508 |
493 |
$24K |
| D1120 |
Prophylaxis - child |
304 |
300 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
671 |
$9K |
| D1206 |
Topical application of fluoride varnish |
438 |
431 |
$8K |
| D4342 |
|
84 |
29 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
40 |
$6K |
| D2394 |
|
23 |
15 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0460 |
|
78 |
77 |
$2K |
| D4910 |
|
15 |
15 |
$960.60 |
| D9310 |
|
15 |
15 |
$518.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$164.17 |
| D0383 |
|
25 |
25 |
$0.00 |