| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,116 |
2,101 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
1,641 |
1,632 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
800 |
799 |
$31K |
| D2740 |
Crown - porcelain/ceramic |
30 |
12 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,503 |
1,469 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
107 |
31 |
$18K |
| D9243 |
|
65 |
47 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
213 |
212 |
$16K |
| D0274 |
Bitewings - four radiographic images |
381 |
377 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
286 |
276 |
$11K |
| D0330 |
Panoramic radiographic image |
108 |
94 |
$6K |
| D9239 |
|
60 |
47 |
$5K |
| D9310 |
|
98 |
84 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
67 |
$2K |
| D4910 |
|
12 |
12 |
$865.69 |