| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
817 |
817 |
$54K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
59 |
44 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
406 |
221 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,402 |
1,114 |
$22K |
| D4341 |
|
310 |
87 |
$22K |
| D0330 |
Panoramic radiographic image |
713 |
713 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
162 |
86 |
$19K |
| D9430 |
|
466 |
408 |
$15K |
| D1110 |
Prophylaxis - adult |
161 |
161 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
257 |
139 |
$14K |
| D0350 |
|
1,204 |
419 |
$12K |
| D1320 |
|
605 |
605 |
$10K |
| D1120 |
Prophylaxis - child |
189 |
189 |
$9K |
| D4910 |
|
101 |
101 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
90 |
$7K |
| D1206 |
Topical application of fluoride varnish |
192 |
192 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
167 |
$2K |
| D0274 |
Bitewings - four radiographic images |
91 |
91 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
154 |
144 |
$2K |
| D2954 |
|
13 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |