| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,733 |
1,727 |
$146K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
182 |
105 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
1,435 |
1,427 |
$75K |
| D2954 |
|
432 |
240 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,287 |
2,213 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
580 |
580 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,263 |
1,257 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,338 |
1,325 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
89 |
58 |
$10K |
| D4341 |
|
86 |
25 |
$5K |
| D9430 |
|
115 |
113 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$764.40 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$0.00 |