| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
943 |
938 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
987 |
980 |
$46K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
80 |
48 |
$38K |
| D1110 |
Prophylaxis - adult |
382 |
375 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
199 |
81 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
94 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
143 |
$3K |
| D0274 |
Bitewings - four radiographic images |
118 |
118 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
24 |
$2K |
| D9110 |
|
16 |
14 |
$819.00 |
| D1351 |
Sealant - per tooth |
37 |
12 |
$704.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
69 |
$567.30 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$480.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
42 |
$363.00 |
| D0270 |
|
12 |
12 |
$60.00 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$0.00 |