| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,967 |
1,962 |
$127K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,354 |
840 |
$90K |
| D0210 |
Intraoral - complete series of radiographic images |
1,765 |
1,763 |
$84K |
| D0350 |
|
8,453 |
2,642 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
497 |
497 |
$36K |
| D9430 |
|
557 |
527 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,000 |
1,050 |
$17K |
| D4341 |
|
162 |
52 |
$11K |
| D4910 |
|
128 |
124 |
$10K |
| D0274 |
Bitewings - four radiographic images |
401 |
401 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
14 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
66 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$6K |
| D1120 |
Prophylaxis - child |
108 |
108 |
$4K |
| D1320 |
|
275 |
275 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
52 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
273 |
268 |
$4K |
| D4342 |
|
81 |
24 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
13 |
$3K |
| D1110 |
Prophylaxis - adult |
22 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
40 |
$442.00 |