| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
977 |
971 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,077 |
1,071 |
$52K |
| D1110 |
Prophylaxis - adult |
495 |
490 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
895 |
889 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,265 |
1,666 |
$31K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
32 |
12 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,298 |
1,289 |
$15K |
| D1120 |
Prophylaxis - child |
395 |
392 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,077 |
1,068 |
$12K |
| D4341 |
|
167 |
44 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
67 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
53 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
40 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
187 |
$2K |
| D0350 |
|
158 |
72 |
$1K |