| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,109 |
1,108 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,208 |
509 |
$66K |
| D1110 |
Prophylaxis - adult |
530 |
529 |
$47K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
95 |
84 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
827 |
827 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
321 |
$34K |
| D1120 |
Prophylaxis - child |
397 |
397 |
$20K |
| D0350 |
|
1,506 |
539 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
935 |
930 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
108 |
69 |
$13K |
| D4910 |
|
136 |
136 |
$10K |
| D9430 |
|
244 |
238 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
85 |
$6K |
| D1351 |
Sealant - per tooth |
142 |
37 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,311 |
333 |
$5K |
| D4341 |
|
70 |
18 |
$5K |
| D2954 |
|
44 |
40 |
$5K |
| D0274 |
Bitewings - four radiographic images |
101 |
101 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$810.00 |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$588.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$201.50 |