| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
950 |
941 |
$63K |
| D2740 |
Crown - porcelain/ceramic |
113 |
70 |
$54K |
| D1110 |
Prophylaxis - adult |
445 |
445 |
$39K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
67 |
32 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
642 |
633 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
378 |
183 |
$21K |
| D2954 |
|
163 |
103 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
139 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
620 |
615 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
70 |
$7K |
| D4341 |
|
66 |
17 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
306 |
301 |
$4K |
| D4910 |
|
42 |
42 |
$3K |
| D9910 |
|
49 |
48 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
13 |
$2K |
| D1320 |
|
105 |
105 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
177 |
$2K |
| D9430 |
|
43 |
42 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$819.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$216.00 |
| D0350 |
|
20 |
12 |
$192.00 |