| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,637 |
2,635 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
2,463 |
2,462 |
$160K |
| D1110 |
Prophylaxis - adult |
1,601 |
1,600 |
$138K |
| D1120 |
Prophylaxis - child |
3,076 |
3,072 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,499 |
868 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
2,029 |
2,028 |
$95K |
| D4910 |
|
855 |
854 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,384 |
4,381 |
$58K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
78 |
57 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,722 |
1,722 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
662 |
390 |
$35K |
| D9430 |
|
1,048 |
1,025 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,522 |
3,134 |
$31K |
| D4341 |
|
293 |
80 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
312 |
168 |
$17K |
| D0350 |
|
1,691 |
777 |
$16K |
| D0272 |
Bitewings - two radiographic images |
965 |
963 |
$11K |
| D0330 |
Panoramic radiographic image |
344 |
344 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
67 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
503 |
484 |
$6K |
| D1206 |
Topical application of fluoride varnish |
322 |
322 |
$4K |
| D1351 |
Sealant - per tooth |
157 |
47 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
44 |
26 |
$3K |
| D4342 |
|
43 |
13 |
$2K |
| D9993 |
|
81 |
81 |
$2K |
| D1310 |
|
87 |
87 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$492.80 |
| D0603 |
|
24 |
24 |
$75.00 |
| D0602 |
|
17 |
16 |
$60.00 |