| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,683 |
1,670 |
$110K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,529 |
596 |
$101K |
| D2740 |
Crown - porcelain/ceramic |
194 |
97 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,175 |
448 |
$63K |
| D1110 |
Prophylaxis - adult |
690 |
684 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
1,204 |
1,194 |
$56K |
| D1120 |
Prophylaxis - child |
1,055 |
1,050 |
$51K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
439 |
228 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
641 |
639 |
$47K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
96 |
52 |
$46K |
| D9430 |
|
855 |
755 |
$27K |
| D0340 |
|
528 |
521 |
$26K |
| D0330 |
Panoramic radiographic image |
870 |
859 |
$24K |
| D4341 |
|
320 |
83 |
$21K |
| D0350 |
|
2,165 |
560 |
$19K |
| D4910 |
|
160 |
157 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,761 |
965 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
685 |
681 |
$10K |
| D1310 |
|
265 |
264 |
$9K |
| D1206 |
Topical application of fluoride varnish |
390 |
389 |
$9K |
| D1351 |
Sealant - per tooth |
247 |
55 |
$9K |
| D0274 |
Bitewings - four radiographic images |
405 |
402 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
33 |
$5K |
| D2330 |
|
64 |
30 |
$5K |
| D2954 |
|
41 |
28 |
$4K |
| D0603 |
|
146 |
145 |
$2K |
| D1320 |
|
141 |
141 |
$2K |
| D4342 |
|
39 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$756.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$180.00 |
| D9993 |
|
200 |
199 |
$0.00 |