| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,616 |
3,590 |
$165K |
| D2740 |
Crown - porcelain/ceramic |
175 |
80 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
3,413 |
3,397 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
3,519 |
3,467 |
$45K |
| D0350 |
|
217 |
164 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
884 |
875 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,042 |
1,038 |
$17K |
| D2950 |
|
128 |
51 |
$17K |
| D0274 |
Bitewings - four radiographic images |
540 |
538 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
198 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
14 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$1K |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$574.56 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$327.70 |