| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
886 |
882 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
643 |
639 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
405 |
403 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
290 |
101 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
178 |
103 |
$12K |
| D0274 |
Bitewings - four radiographic images |
361 |
359 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
13 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,734 |
641 |
$7K |
| D0350 |
|
651 |
298 |
$7K |
| D1120 |
Prophylaxis - child |
153 |
153 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
39 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
18 |
$3K |
| D2140 |
|
30 |
15 |
$2K |
| D2954 |
|
14 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$990.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
73 |
$633.00 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$264.00 |