| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,998 |
1,998 |
$131K |
| D1110 |
Prophylaxis - adult |
1,106 |
1,106 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,420 |
626 |
$94K |
| D0210 |
Intraoral - complete series of radiographic images |
1,950 |
1,950 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,631 |
655 |
$88K |
| D4341 |
|
438 |
121 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
373 |
144 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,152 |
1,151 |
$19K |
| D2740 |
Crown - porcelain/ceramic |
39 |
28 |
$19K |
| D9430 |
|
574 |
532 |
$18K |
| D1120 |
Prophylaxis - child |
167 |
166 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
64 |
$7K |
| D4910 |
|
62 |
62 |
$5K |
| D4342 |
|
94 |
27 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$2K |
| D2330 |
|
18 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
256 |
185 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$842.40 |
| D0270 |
|
46 |
43 |
$230.00 |