| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,777 |
1,777 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
1,944 |
1,943 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,401 |
571 |
$94K |
| D2740 |
Crown - porcelain/ceramic |
168 |
112 |
$80K |
| D1120 |
Prophylaxis - child |
1,859 |
1,856 |
$63K |
| D9430 |
|
1,840 |
1,618 |
$59K |
| D1351 |
Sealant - per tooth |
2,523 |
676 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
840 |
840 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
709 |
355 |
$38K |
| D0330 |
Panoramic radiographic image |
1,198 |
1,197 |
$35K |
| D0350 |
|
3,082 |
960 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,329 |
2,328 |
$26K |
| D0274 |
Bitewings - four radiographic images |
739 |
738 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,400 |
1,220 |
$13K |
| D2954 |
|
96 |
65 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
56 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
13 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
37 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
38 |
$5K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$4K |
| D4341 |
|
45 |
12 |
$3K |
| D2330 |
|
37 |
13 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
17 |
$3K |
| D0272 |
Bitewings - two radiographic images |
128 |
128 |
$2K |
| D4910 |
|
14 |
14 |
$1K |
| D1999 |
|
144 |
135 |
$184.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |