| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,548 |
4,539 |
$193K |
| D2740 |
Crown - porcelain/ceramic |
270 |
170 |
$183K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,783 |
1,224 |
$177K |
| D0210 |
Intraoral - complete series of radiographic images |
2,804 |
2,731 |
$147K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,202 |
690 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,450 |
3,442 |
$113K |
| D2950 |
|
650 |
487 |
$109K |
| D0140 |
Limited oral evaluation - problem focused |
3,255 |
3,208 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
4,298 |
4,288 |
$100K |
| D0274 |
Bitewings - four radiographic images |
2,623 |
2,617 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
5,653 |
5,509 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
542 |
430 |
$64K |
| D4341 |
|
398 |
147 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,660 |
4,088 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
613 |
413 |
$47K |
| D0330 |
Panoramic radiographic image |
749 |
748 |
$34K |
| D2790 |
|
36 |
30 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
200 |
137 |
$21K |
| D1206 |
Topical application of fluoride varnish |
792 |
790 |
$19K |
| D4910 |
|
191 |
191 |
$17K |
| D1120 |
Prophylaxis - child |
377 |
376 |
$16K |
| D5110 |
|
12 |
12 |
$7K |
| D4346 |
|
110 |
110 |
$7K |
| D1351 |
Sealant - per tooth |
90 |
26 |
$3K |
| D2394 |
|
34 |
27 |
$2K |
| D4355 |
|
19 |
19 |
$496.68 |