| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,016 |
1,283 |
$217K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,135 |
930 |
$142K |
| D1110 |
Prophylaxis - adult |
1,536 |
1,529 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
1,549 |
1,542 |
$108K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
194 |
128 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,290 |
1,287 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,315 |
2,434 |
$54K |
| D2330 |
|
626 |
212 |
$49K |
| D1120 |
Prophylaxis - child |
1,050 |
1,038 |
$43K |
| D0274 |
Bitewings - four radiographic images |
2,052 |
2,040 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,827 |
2,809 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
642 |
642 |
$30K |
| D0350 |
|
1,479 |
727 |
$19K |
| D9430 |
|
542 |
446 |
$17K |
| D4341 |
|
153 |
42 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
71 |
$9K |
| D2954 |
|
47 |
28 |
$5K |
| D4910 |
|
36 |
36 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
12 |
$660.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
13 |
$163.50 |