| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
959 |
959 |
$48K |
| D0330 |
Panoramic radiographic image |
818 |
817 |
$44K |
| D0350 |
|
860 |
758 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
628 |
627 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
660 |
635 |
$25K |
| D0274 |
Bitewings - four radiographic images |
720 |
720 |
$22K |
| D2740 |
Crown - porcelain/ceramic |
31 |
27 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
495 |
495 |
$13K |
| D0460 |
|
462 |
431 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
43 |
$8K |
| D2950 |
|
61 |
55 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
21 |
$7K |
| D4342 |
|
40 |
12 |
$4K |
| D2394 |
|
18 |
13 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
15 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
211 |
$3K |