| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
940 |
933 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
990 |
982 |
$65K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
120 |
74 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
808 |
474 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
874 |
866 |
$42K |
| D0350 |
|
4,140 |
1,151 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
768 |
394 |
$40K |
| D4341 |
|
565 |
160 |
$40K |
| D4910 |
|
456 |
456 |
$35K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
284 |
163 |
$34K |
| D2330 |
|
299 |
143 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
261 |
261 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,219 |
1,209 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,879 |
583 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
59 |
$7K |
| D0274 |
Bitewings - four radiographic images |
173 |
173 |
$4K |
| D9430 |
|
102 |
96 |
$3K |
| D4342 |
|
32 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |