| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,015 |
2,997 |
$256K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,677 |
2,662 |
$165K |
| D0210 |
Intraoral - complete series of radiographic images |
2,124 |
2,099 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
606 |
180 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
299 |
208 |
$33K |
| D1120 |
Prophylaxis - child |
933 |
933 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
403 |
77 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
328 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,357 |
1,338 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
68 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,971 |
1,699 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
12 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
12 |
$8K |
| D4341 |
|
43 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
236 |
236 |
$2K |
| D2394 |
|
25 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$1K |
| D0350 |
|
201 |
92 |
$751.20 |