| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,087 |
1,087 |
$71K |
| D2740 |
Crown - porcelain/ceramic |
125 |
87 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
701 |
352 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
817 |
817 |
$39K |
| D1110 |
Prophylaxis - adult |
414 |
414 |
$36K |
| D4341 |
|
358 |
117 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
447 |
250 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
197 |
72 |
$23K |
| D1120 |
Prophylaxis - child |
441 |
441 |
$21K |
| D0330 |
Panoramic radiographic image |
542 |
541 |
$16K |
| D1351 |
Sealant - per tooth |
430 |
112 |
$16K |
| D1206 |
Topical application of fluoride varnish |
881 |
880 |
$15K |
| D0350 |
|
1,363 |
499 |
$13K |
| D1310 |
|
87 |
87 |
$4K |
| D4910 |
|
46 |
46 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
831 |
150 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
35 |
35 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D4342 |
|
26 |
13 |
$924.00 |
| D0603 |
|
38 |
38 |
$557.00 |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$492.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$180.00 |