| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,355 |
2,338 |
$200K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,404 |
1,398 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,333 |
1,327 |
$87K |
| D0274 |
Bitewings - four radiographic images |
2,946 |
2,936 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,095 |
3,697 |
$49K |
| D9430 |
|
1,019 |
1,006 |
$32K |
| D1120 |
Prophylaxis - child |
768 |
767 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
267 |
266 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
978 |
969 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
12 |
12 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
38 |
$4K |
| D4910 |
|
37 |
37 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
69 |
$636.00 |