| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,114 |
1,107 |
$60K |
| D2740 |
Crown - porcelain/ceramic |
75 |
50 |
$54K |
| D0140 |
Limited oral evaluation - problem focused |
1,270 |
1,246 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
715 |
386 |
$46K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
317 |
157 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,714 |
1,705 |
$42K |
| D1120 |
Prophylaxis - child |
674 |
673 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,268 |
2,066 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
714 |
706 |
$31K |
| D0274 |
Bitewings - four radiographic images |
736 |
733 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
210 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
302 |
296 |
$21K |
| D1206 |
Topical application of fluoride varnish |
756 |
755 |
$19K |
| D2954 |
|
54 |
38 |
$10K |
| D4342 |
|
95 |
36 |
$8K |
| D1351 |
Sealant - per tooth |
96 |
32 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
243 |
183 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
14 |
$2K |
| D0180 |
|
13 |
13 |
$444.00 |