| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,305 |
1,303 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
1,065 |
1,059 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
920 |
473 |
$61K |
| D1120 |
Prophylaxis - child |
1,287 |
1,275 |
$52K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
365 |
123 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,420 |
2,080 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
680 |
678 |
$31K |
| D9430 |
|
878 |
740 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
496 |
256 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,183 |
1,179 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
47 |
38 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,221 |
1,213 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
119 |
90 |
$9K |
| D1110 |
Prophylaxis - adult |
102 |
101 |
$8K |
| D1351 |
Sealant - per tooth |
381 |
85 |
$8K |
| D4341 |
|
46 |
19 |
$3K |
| D2954 |
|
29 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
134 |
132 |
$2K |
| D1320 |
|
84 |
84 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
46 |
$588.00 |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$266.00 |
| D1330 |
|
42 |
42 |
$0.00 |
| D1310 |
|
82 |
82 |
$0.00 |