| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,924 |
1,919 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,342 |
1,337 |
$83K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
122 |
84 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
1,046 |
1,042 |
$48K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
255 |
141 |
$29K |
| D4341 |
|
404 |
107 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
165 |
$15K |
| D4910 |
|
117 |
117 |
$9K |
| D5110 |
|
12 |
12 |
$8K |
| D1120 |
Prophylaxis - child |
225 |
225 |
$7K |
| D1110 |
Prophylaxis - adult |
65 |
63 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,159 |
380 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
276 |
276 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D2954 |
|
13 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$466.00 |