| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,976 |
1,964 |
$170K |
| D0120 |
Periodic oral evaluation - established patient |
2,991 |
2,971 |
$163K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,314 |
1,308 |
$85K |
| D1120 |
Prophylaxis - child |
1,902 |
1,893 |
$71K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
146 |
113 |
$69K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
536 |
240 |
$62K |
| D0210 |
Intraoral - complete series of radiographic images |
1,089 |
1,084 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,967 |
3,945 |
$50K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
77 |
66 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
242 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,812 |
1,790 |
$21K |
| D1351 |
Sealant - per tooth |
619 |
121 |
$15K |
| D2954 |
|
134 |
106 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
137 |
83 |
$11K |
| D3221 |
|
58 |
56 |
$4K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
25 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
64 |
$567.00 |