| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
900 |
890 |
$59K |
| D2740 |
Crown - porcelain/ceramic |
91 |
60 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
684 |
679 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
255 |
96 |
$30K |
| D1110 |
Prophylaxis - adult |
326 |
323 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
85 |
$12K |
| D4341 |
|
164 |
43 |
$11K |
| D1206 |
Topical application of fluoride varnish |
669 |
660 |
$11K |
| D1120 |
Prophylaxis - child |
177 |
172 |
$9K |
| D7230 |
|
30 |
17 |
$5K |
| D0350 |
|
395 |
125 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$3K |
| D4910 |
|
40 |
40 |
$3K |
| D1351 |
Sealant - per tooth |
77 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
451 |
146 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D9430 |
|
49 |
46 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
15 |
$1K |
| D1320 |
|
88 |
88 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$496.80 |