| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,052 |
3,023 |
$172K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,286 |
531 |
$152K |
| D0210 |
Intraoral - complete series of radiographic images |
2,243 |
2,225 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
1,708 |
1,665 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,730 |
3,132 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,561 |
1,543 |
$28K |
| D1110 |
Prophylaxis - adult |
332 |
328 |
$25K |
| D0350 |
|
2,546 |
927 |
$24K |
| D1120 |
Prophylaxis - child |
578 |
567 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
129 |
$16K |
| D9430 |
|
411 |
396 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
14 |
$9K |
| D0330 |
Panoramic radiographic image |
710 |
703 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
531 |
527 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
40 |
$5K |
| D4341 |
|
68 |
30 |
$4K |
| D1320 |
|
149 |
149 |
$2K |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$672.00 |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
139 |
$420.00 |
| D0270 |
|
25 |
24 |
$115.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$36.00 |