| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,798 |
1,793 |
$118K |
| D1110 |
Prophylaxis - adult |
1,072 |
1,064 |
$93K |
| D0210 |
Intraoral - complete series of radiographic images |
1,503 |
1,499 |
$71K |
| D0340 |
|
1,351 |
1,348 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
845 |
840 |
$63K |
| D0330 |
Panoramic radiographic image |
1,745 |
1,735 |
$50K |
| D4910 |
|
599 |
594 |
$45K |
| D9430 |
|
1,348 |
1,283 |
$43K |
| D1120 |
Prophylaxis - child |
749 |
745 |
$36K |
| D1206 |
Topical application of fluoride varnish |
2,009 |
1,997 |
$32K |
| D2740 |
Crown - porcelain/ceramic |
46 |
37 |
$22K |
| D0350 |
|
2,100 |
726 |
$20K |
| D0274 |
Bitewings - four radiographic images |
939 |
933 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
242 |
137 |
$16K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
28 |
24 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,903 |
1,567 |
$12K |
| D4341 |
|
115 |
30 |
$8K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
23 |
13 |
$5K |
| D1351 |
Sealant - per tooth |
173 |
27 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
33 |
$3K |
| D9222 |
|
13 |
13 |
$2K |
| D9610 |
|
15 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
66 |
$500.50 |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$168.00 |
| D0270 |
|
15 |
15 |
$55.00 |