| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
533 |
533 |
$35K |
| D1110 |
Prophylaxis - adult |
323 |
323 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
302 |
120 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
411 |
411 |
$19K |
| D0350 |
|
1,866 |
425 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
58 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
18 |
15 |
$9K |
| D9430 |
|
229 |
207 |
$7K |
| D1206 |
Topical application of fluoride varnish |
241 |
241 |
$4K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
129 |
$927.45 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$475.20 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$324.00 |
| D0270 |
|
32 |
30 |
$160.00 |