| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
783 |
773 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
678 |
671 |
$32K |
| D1110 |
Prophylaxis - adult |
279 |
279 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
352 |
174 |
$21K |
| D0350 |
|
1,220 |
380 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
98 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
151 |
151 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
88 |
44 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
610 |
610 |
$9K |
| D1120 |
Prophylaxis - child |
168 |
168 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,705 |
337 |
$7K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$7K |
| D4341 |
|
52 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
154 |
153 |
$3K |
| D4910 |
|
28 |
28 |
$2K |
| D2954 |
|
17 |
13 |
$2K |
| D9430 |
|
45 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$144.00 |