| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,623 |
1,596 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
1,280 |
1,261 |
$31K |
| D2740 |
Crown - porcelain/ceramic |
40 |
27 |
$30K |
| D0274 |
Bitewings - four radiographic images |
925 |
911 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,036 |
996 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,621 |
779 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
336 |
333 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
83 |
$9K |
| D0330 |
Panoramic radiographic image |
180 |
178 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
123 |
$4K |
| D2950 |
|
19 |
12 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
42 |
$3K |
| D1206 |
Topical application of fluoride varnish |
107 |
106 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$832.54 |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
17 |
$663.12 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$542.00 |