| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
586 |
574 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
773 |
756 |
$51K |
| D4341 |
|
720 |
191 |
$50K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
94 |
56 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
665 |
649 |
$32K |
| D4910 |
|
237 |
237 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
801 |
785 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
70 |
$11K |
| D9430 |
|
332 |
305 |
$11K |
| D1120 |
Prophylaxis - child |
187 |
181 |
$10K |
| D2954 |
|
69 |
47 |
$7K |
| D1351 |
Sealant - per tooth |
193 |
37 |
$7K |
| D0330 |
Panoramic radiographic image |
176 |
172 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
54 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
38 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
252 |
226 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
643 |
383 |
$3K |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$2K |
| D4342 |
|
33 |
12 |
$1K |
| D5850 |
|
15 |
13 |
$1K |
| D1320 |
|
25 |
25 |
$420.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$288.00 |