| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,316 |
2,301 |
$153K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
982 |
493 |
$116K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
183 |
143 |
$87K |
| D1110 |
Prophylaxis - adult |
967 |
961 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,103 |
630 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
768 |
762 |
$62K |
| D9430 |
|
1,593 |
1,474 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
990 |
990 |
$47K |
| D1120 |
Prophylaxis - child |
933 |
921 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,125 |
2,277 |
$46K |
| D4341 |
|
618 |
167 |
$43K |
| D4910 |
|
544 |
537 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,483 |
1,462 |
$31K |
| D1351 |
Sealant - per tooth |
756 |
156 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,544 |
1,531 |
$23K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
27 |
24 |
$12K |
| D0350 |
|
729 |
349 |
$7K |
| D1206 |
Topical application of fluoride varnish |
386 |
386 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
68 |
$5K |
| D0330 |
Panoramic radiographic image |
142 |
142 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
28 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D1320 |
|
75 |
75 |
$1K |
| D0272 |
Bitewings - two radiographic images |
78 |
78 |
$936.00 |
| D9930 |
|
33 |
33 |
$663.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$472.00 |