| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,313 |
1,312 |
$87K |
| D1110 |
Prophylaxis - adult |
843 |
843 |
$75K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
122 |
97 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
698 |
347 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
907 |
907 |
$43K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
296 |
178 |
$35K |
| D2740 |
Crown - porcelain/ceramic |
70 |
58 |
$33K |
| D0330 |
Panoramic radiographic image |
1,035 |
1,034 |
$31K |
| D1120 |
Prophylaxis - child |
573 |
573 |
$29K |
| D9430 |
|
829 |
740 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
277 |
$23K |
| D2954 |
|
220 |
179 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,274 |
1,274 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,463 |
1,035 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
137 |
99 |
$11K |
| D0350 |
|
1,067 |
278 |
$10K |
| D0274 |
Bitewings - four radiographic images |
355 |
355 |
$8K |
| D1351 |
Sealant - per tooth |
134 |
29 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
246 |
$3K |
| D1320 |
|
119 |
119 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
96 |
96 |
$1K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$984.00 |
| D0270 |
|
24 |
24 |
$108.75 |