| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,208 |
2,201 |
$142K |
| D0120 |
Periodic oral evaluation - established patient |
2,569 |
2,551 |
$132K |
| D2740 |
Crown - porcelain/ceramic |
199 |
168 |
$94K |
| D1110 |
Prophylaxis - adult |
1,102 |
1,096 |
$91K |
| D1120 |
Prophylaxis - child |
2,002 |
1,989 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,028 |
620 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,779 |
4,453 |
$67K |
| D0274 |
Bitewings - four radiographic images |
3,152 |
3,133 |
$66K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
853 |
498 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
746 |
742 |
$35K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
188 |
57 |
$29K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
240 |
98 |
$28K |
| D2160 |
|
251 |
184 |
$20K |
| D9430 |
|
599 |
579 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,752 |
1,748 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
319 |
201 |
$17K |
| D4341 |
|
196 |
51 |
$14K |
| D2954 |
|
66 |
53 |
$7K |
| D9222 |
|
56 |
56 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
65 |
$6K |
| D2140 |
|
115 |
81 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
445 |
436 |
$5K |
| D2330 |
|
20 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$810.00 |
| D1351 |
Sealant - per tooth |
36 |
12 |
$672.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |