| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,084 |
2,050 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,261 |
1,230 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,500 |
1,478 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
51 |
36 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
3,424 |
3,243 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
260 |
124 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
267 |
267 |
$10K |
| D0274 |
Bitewings - four radiographic images |
1,583 |
1,524 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,442 |
2,356 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
754 |
717 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
54 |
$4K |
| D0330 |
Panoramic radiographic image |
903 |
862 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
82 |
81 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
61 |
$328.00 |
| D9310 |
|
12 |
12 |
$281.60 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$96.00 |