| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
746 |
746 |
$49K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
92 |
56 |
$44K |
| D1110 |
Prophylaxis - adult |
319 |
319 |
$28K |
| D4910 |
|
317 |
317 |
$24K |
| D1120 |
Prophylaxis - child |
359 |
359 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
138 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
297 |
149 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
131 |
70 |
$15K |
| D4341 |
|
209 |
66 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
304 |
304 |
$15K |
| D1206 |
Topical application of fluoride varnish |
705 |
705 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,695 |
390 |
$7K |
| D9430 |
|
216 |
207 |
$7K |
| D0330 |
Panoramic radiographic image |
172 |
172 |
$5K |
| D2330 |
|
57 |
34 |
$5K |
| D0350 |
|
404 |
168 |
$4K |
| D1351 |
Sealant - per tooth |
73 |
18 |
$3K |
| D2954 |
|
24 |
15 |
$3K |
| D1310 |
|
31 |
31 |
$1K |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
106 |
102 |
$1K |
| D0603 |
|
29 |
29 |
$435.00 |