| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,101 |
1,098 |
$73K |
| D2740 |
Crown - porcelain/ceramic |
152 |
102 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
989 |
478 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
817 |
810 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
814 |
378 |
$44K |
| D1120 |
Prophylaxis - child |
950 |
942 |
$41K |
| D1110 |
Prophylaxis - adult |
335 |
334 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,908 |
1,573 |
$24K |
| D4910 |
|
287 |
287 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
414 |
413 |
$20K |
| D0350 |
|
1,377 |
733 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,235 |
1,225 |
$15K |
| D4341 |
|
205 |
55 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
56 |
38 |
$7K |
| D1351 |
Sealant - per tooth |
195 |
55 |
$6K |
| D1206 |
Topical application of fluoride varnish |
504 |
504 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
13 |
$957.60 |
| D9430 |
|
13 |
12 |
$416.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
15 |
$222.50 |
| D1330 |
|
85 |
84 |
$0.00 |