| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
850 |
849 |
$76K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,084 |
2,438 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
900 |
899 |
$58K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
108 |
72 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
699 |
699 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,985 |
1,982 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
69 |
42 |
$8K |
| D1120 |
Prophylaxis - child |
159 |
159 |
$6K |
| D4341 |
|
84 |
29 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$2K |
| D0350 |
|
161 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
53 |
$660.00 |