| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,542 |
1,230 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
2,698 |
2,689 |
$162K |
| D1120 |
Prophylaxis - child |
2,493 |
2,481 |
$101K |
| D1110 |
Prophylaxis - adult |
1,067 |
1,061 |
$91K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,544 |
790 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,125 |
1,115 |
$73K |
| D1206 |
Topical application of fluoride varnish |
3,812 |
3,793 |
$50K |
| D0274 |
Bitewings - four radiographic images |
2,366 |
2,355 |
$46K |
| D2740 |
Crown - porcelain/ceramic |
90 |
63 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
810 |
806 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,059 |
3,146 |
$24K |
| D1351 |
Sealant - per tooth |
419 |
149 |
$14K |
| D0350 |
|
1,348 |
662 |
$13K |
| D9430 |
|
236 |
227 |
$7K |
| D2954 |
|
66 |
48 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
58 |
37 |
$7K |
| D4341 |
|
63 |
15 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
247 |
$3K |
| D0272 |
Bitewings - two radiographic images |
183 |
182 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |