| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,148 |
4,134 |
$275K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,725 |
1,934 |
$244K |
| D0120 |
Periodic oral evaluation - established patient |
2,236 |
2,228 |
$154K |
| D0210 |
Intraoral - complete series of radiographic images |
3,168 |
3,159 |
$149K |
| D1110 |
Prophylaxis - adult |
1,606 |
1,601 |
$137K |
| D1120 |
Prophylaxis - child |
3,033 |
3,019 |
$135K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
172 |
141 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,163 |
624 |
$61K |
| D1206 |
Topical application of fluoride varnish |
3,380 |
3,355 |
$60K |
| D7140 |
Extraction, erupted tooth or exposed root |
697 |
312 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
502 |
361 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,746 |
1,737 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,685 |
1,683 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
47 |
33 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,854 |
1,678 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
150 |
95 |
$18K |
| D1310 |
|
364 |
361 |
$14K |
| D1320 |
|
407 |
403 |
$7K |
| D1351 |
Sealant - per tooth |
220 |
61 |
$7K |
| D0350 |
|
845 |
364 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
463 |
460 |
$6K |
| D9993 |
|
63 |
63 |
$3K |
| D4341 |
|
46 |
15 |
$3K |
| D2335 |
|
29 |
13 |
$3K |
| D2331 |
|
26 |
14 |
$2K |
| D4910 |
|
12 |
12 |
$995.00 |
| D1999 |
|
4,757 |
4,123 |
$993.50 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$814.00 |
| D0272 |
Bitewings - two radiographic images |
51 |
50 |
$605.00 |
| D0601 |
|
26 |
26 |
$360.00 |
| D0603 |
|
26 |
26 |
$300.00 |