| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,471 |
2,461 |
$162K |
| D1110 |
Prophylaxis - adult |
1,249 |
1,244 |
$108K |
| D0210 |
Intraoral - complete series of radiographic images |
2,033 |
2,026 |
$96K |
| D1351 |
Sealant - per tooth |
3,179 |
570 |
$82K |
| D1120 |
Prophylaxis - child |
1,608 |
1,598 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
886 |
879 |
$63K |
| D9430 |
|
1,250 |
1,219 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,271 |
1,580 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,795 |
1,780 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,276 |
1,276 |
$21K |
| D4341 |
|
260 |
69 |
$18K |
| D0274 |
Bitewings - four radiographic images |
782 |
776 |
$16K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
22 |
17 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
722 |
713 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
55 |
42 |
$7K |
| D4910 |
|
72 |
72 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
27 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
25 |
$3K |
| D2954 |
|
19 |
15 |
$2K |
| D0350 |
|
84 |
27 |
$768.00 |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$444.00 |