| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
484 |
477 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
248 |
240 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
301 |
$5K |
| D0330 |
Panoramic radiographic image |
99 |
99 |
$4K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
29 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
95 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
407 |
402 |
$2K |
| D0274 |
Bitewings - four radiographic images |
127 |
125 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
278 |
261 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
15 |
$715.00 |
| D2954 |
|
21 |
18 |
$475.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$400.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
21 |
$372.00 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$161.00 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$105.00 |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
23 |
$36.50 |
| D9920 |
|
15 |
14 |
$0.00 |