| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,473 |
4,443 |
$282K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,254 |
1,599 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
3,595 |
3,550 |
$181K |
| D0210 |
Intraoral - complete series of radiographic images |
3,264 |
3,238 |
$148K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,190 |
1,073 |
$116K |
| D1120 |
Prophylaxis - child |
3,142 |
3,113 |
$110K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,997 |
5,084 |
$93K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
567 |
288 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
783 |
275 |
$62K |
| D0274 |
Bitewings - four radiographic images |
2,485 |
2,448 |
$47K |
| D2332 |
|
598 |
107 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,578 |
2,555 |
$24K |
| D1110 |
Prophylaxis - adult |
274 |
271 |
$21K |
| D9430 |
|
501 |
473 |
$16K |
| D4910 |
|
118 |
117 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
12 |
$6K |
| D4341 |
|
75 |
25 |
$5K |
| D2394 |
|
55 |
26 |
$5K |
| D1351 |
Sealant - per tooth |
206 |
58 |
$4K |
| D0272 |
Bitewings - two radiographic images |
304 |
303 |
$4K |
| D2954 |
|
12 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$720.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$285.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$144.00 |