| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
797 |
795 |
$52K |
| D9430 |
|
1,237 |
1,065 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
585 |
584 |
$27K |
| D1110 |
Prophylaxis - adult |
277 |
271 |
$23K |
| D0350 |
|
2,700 |
599 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
37 |
31 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,907 |
1,046 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
117 |
115 |
$8K |
| D1320 |
|
554 |
546 |
$8K |
| D0274 |
Bitewings - four radiographic images |
356 |
349 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
29 |
$7K |
| D4341 |
|
95 |
27 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
377 |
368 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
29 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
31 |
$4K |
| D4910 |
|
42 |
42 |
$3K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D1206 |
Topical application of fluoride varnish |
102 |
102 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
78 |
$1K |
| D0270 |
|
195 |
189 |
$958.75 |