| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,404 |
1,399 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
1,402 |
1,399 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,207 |
581 |
$79K |
| D1120 |
Prophylaxis - child |
1,523 |
1,518 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
1,036 |
1,035 |
$48K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,160 |
2,219 |
$37K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
73 |
44 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
566 |
283 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,435 |
1,430 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,887 |
1,883 |
$23K |
| D4341 |
|
74 |
20 |
$5K |
| D9430 |
|
109 |
106 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D0270 |
|
59 |
57 |
$290.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$100.00 |