| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
507 |
507 |
$33K |
| D4910 |
|
426 |
426 |
$33K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
56 |
41 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
423 |
423 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
292 |
120 |
$20K |
| D1110 |
Prophylaxis - adult |
186 |
186 |
$17K |
| D4341 |
|
235 |
63 |
$16K |
| D1120 |
Prophylaxis - child |
155 |
155 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
63 |
37 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
403 |
402 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
442 |
422 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
32 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,099 |
389 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
31 |
$4K |
| D2335 |
|
30 |
12 |
$3K |
| D0350 |
|
357 |
137 |
$3K |
| D9430 |
|
70 |
69 |
$2K |
| D2954 |
|
17 |
15 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$630.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |