| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,644 |
2,644 |
$92K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,763 |
2,758 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
1,661 |
1,660 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,719 |
1,719 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,142 |
1,141 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
35 |
17 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
88 |
81 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
67 |
$5K |
| D0272 |
Bitewings - two radiographic images |
278 |
278 |
$3K |
| D2954 |
|
37 |
18 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$703.30 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
75 |
$696.78 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$305.32 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$124.88 |