| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
625 |
614 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
608 |
598 |
$28K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
50 |
24 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
164 |
62 |
$17K |
| D1110 |
Prophylaxis - adult |
182 |
178 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
57 |
$7K |
| D4910 |
|
88 |
88 |
$7K |
| D1206 |
Topical application of fluoride varnish |
178 |
178 |
$3K |
| D4341 |
|
40 |
12 |
$3K |
| D9430 |
|
81 |
76 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
32 |
31 |
$2K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$583.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$472.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
29 |
$336.15 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$153.00 |
| D0350 |
|
40 |
12 |
$9.60 |