| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,354 |
2,348 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
1,960 |
1,952 |
$131K |
| D0210 |
Intraoral - complete series of radiographic images |
1,990 |
1,980 |
$94K |
| D1120 |
Prophylaxis - child |
1,656 |
1,651 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,140 |
3,149 |
$58K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
117 |
93 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
691 |
511 |
$45K |
| D1110 |
Prophylaxis - adult |
512 |
510 |
$45K |
| D9430 |
|
1,412 |
1,392 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,186 |
3,177 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,527 |
1,527 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
421 |
307 |
$23K |
| D4910 |
|
255 |
255 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
245 |
171 |
$16K |
| D0350 |
|
1,304 |
828 |
$13K |
| D1320 |
|
716 |
703 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
917 |
908 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
85 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
65 |
41 |
$8K |
| D2954 |
|
53 |
44 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$2K |
| D4342 |
|
36 |
12 |
$2K |
| D2140 |
|
18 |
15 |
$982.80 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |