| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,292 |
2,284 |
$147K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,825 |
1,201 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
1,660 |
1,656 |
$113K |
| D1120 |
Prophylaxis - child |
2,201 |
2,192 |
$95K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,306 |
896 |
$71K |
| D0210 |
Intraoral - complete series of radiographic images |
1,472 |
1,469 |
$70K |
| D1110 |
Prophylaxis - adult |
731 |
728 |
$63K |
| D9430 |
|
1,557 |
1,489 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,964 |
2,955 |
$42K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
67 |
57 |
$31K |
| D0350 |
|
2,233 |
1,360 |
$21K |
| D0274 |
Bitewings - four radiographic images |
923 |
922 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
210 |
160 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,367 |
1,330 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,648 |
1,840 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
25 |
$7K |
| D4910 |
|
26 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$468.00 |