| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
791 |
789 |
$52K |
| D1110 |
Prophylaxis - adult |
558 |
555 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
744 |
741 |
$35K |
| D9430 |
|
1,068 |
1,037 |
$34K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
53 |
39 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
352 |
202 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,306 |
1,260 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
175 |
175 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,450 |
1,070 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
104 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$2K |
| D2330 |
|
26 |
12 |
$2K |
| D2954 |
|
15 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |
| D1999 |
|
14 |
14 |
$0.00 |