| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,681 |
1,677 |
$143K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,087 |
2,085 |
$133K |
| D0210 |
Intraoral - complete series of radiographic images |
1,692 |
1,689 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,405 |
1,396 |
$77K |
| D1120 |
Prophylaxis - child |
1,679 |
1,672 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,250 |
4,232 |
$56K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
425 |
184 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,038 |
1,805 |
$35K |
| D0274 |
Bitewings - four radiographic images |
898 |
898 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
33 |
27 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
220 |
122 |
$15K |
| D4341 |
|
124 |
34 |
$9K |
| D2140 |
|
44 |
29 |
$2K |
| D0350 |
|
60 |
36 |
$614.40 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$456.00 |