| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
859 |
852 |
$56K |
| D1110 |
Prophylaxis - adult |
389 |
387 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,309 |
1,272 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
171 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
40 |
27 |
$19K |
| D0274 |
Bitewings - four radiographic images |
724 |
713 |
$15K |
| D4341 |
|
187 |
51 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
127 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
85 |
39 |
$10K |
| D1120 |
Prophylaxis - child |
89 |
89 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
237 |
234 |
$3K |
| D9430 |
|
75 |
74 |
$2K |
| D0350 |
|
499 |
208 |
$2K |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$860.00 |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$455.50 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |