| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
627 |
626 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
552 |
551 |
$26K |
| D9430 |
|
783 |
717 |
$25K |
| D1110 |
Prophylaxis - adult |
254 |
254 |
$22K |
| D2394 |
|
180 |
87 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
88 |
52 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
69 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
12 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
29 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
275 |
275 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
250 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
672 |
418 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
27 |
$3K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$577.50 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$248.00 |