| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,178 |
2,175 |
$188K |
| D2740 |
Crown - porcelain/ceramic |
320 |
224 |
$152K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,870 |
1,868 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
1,663 |
1,655 |
$105K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
811 |
456 |
$95K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,766 |
2,763 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
562 |
348 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,010 |
1,714 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,570 |
1,567 |
$33K |
| D0330 |
Panoramic radiographic image |
990 |
990 |
$28K |
| D9430 |
|
624 |
595 |
$19K |
| D2954 |
|
91 |
76 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
40 |
$4K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$312.00 |