| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,702 |
2,685 |
$159K |
| D0120 |
Periodic oral evaluation - established patient |
3,407 |
3,367 |
$146K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
932 |
409 |
$106K |
| D1120 |
Prophylaxis - child |
2,510 |
2,489 |
$82K |
| D0210 |
Intraoral - complete series of radiographic images |
1,945 |
1,936 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,010 |
4,967 |
$66K |
| D0274 |
Bitewings - four radiographic images |
3,168 |
3,142 |
$49K |
| D1110 |
Prophylaxis - adult |
710 |
706 |
$49K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
75 |
45 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,608 |
2,588 |
$33K |
| D9430 |
|
654 |
647 |
$19K |
| D0350 |
|
2,029 |
528 |
$17K |
| D1351 |
Sealant - per tooth |
390 |
91 |
$13K |
| D4341 |
|
157 |
57 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
84 |
$9K |
| D9999 |
Unspecified adjunctive procedure, by report |
57 |
57 |
$8K |
| D0330 |
Panoramic radiographic image |
300 |
299 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
25 |
$4K |
| D0272 |
Bitewings - two radiographic images |
214 |
213 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
363 |
$2K |
| D9993 |
|
15 |
15 |
$845.00 |
| D4910 |
|
12 |
12 |
$704.00 |
| D1310 |
|
15 |
15 |
$644.00 |
| D1330 |
|
45 |
41 |
$0.00 |