| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
910 |
910 |
$60K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
80 |
63 |
$38K |
| D1351 |
Sealant - per tooth |
984 |
217 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
645 |
645 |
$31K |
| D4341 |
|
410 |
110 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
127 |
$19K |
| D1120 |
Prophylaxis - child |
311 |
311 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
89 |
34 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
59 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
367 |
367 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,379 |
283 |
$5K |
| D4342 |
|
97 |
33 |
$4K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$4K |
| D0350 |
|
324 |
134 |
$3K |
| D4910 |
|
34 |
34 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
12 |
$3K |
| D2954 |
|
21 |
18 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
31 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
44 |
43 |
$2K |
| D0272 |
Bitewings - two radiographic images |
133 |
133 |
$2K |
| D9430 |
|
44 |
43 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$1K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
44 |
$528.00 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$430.00 |