| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,383 |
600 |
$91K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,079 |
409 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,311 |
1,310 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,197 |
489 |
$65K |
| D1110 |
Prophylaxis - adult |
683 |
682 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
957 |
955 |
$45K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
87 |
67 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
393 |
392 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,875 |
1,873 |
$23K |
| D1120 |
Prophylaxis - child |
615 |
614 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
287 |
105 |
$19K |
| D4341 |
|
252 |
70 |
$17K |
| D9430 |
|
538 |
456 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,519 |
1,302 |
$17K |
| D0350 |
|
1,972 |
456 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
716 |
661 |
$8K |
| D2140 |
|
140 |
53 |
$8K |
| D2954 |
|
71 |
57 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
49 |
27 |
$6K |
| D0274 |
Bitewings - four radiographic images |
209 |
209 |
$4K |
| D2160 |
|
51 |
28 |
$4K |
| D4910 |
|
25 |
25 |
$2K |
| D2330 |
|
20 |
13 |
$2K |
| D2940 |
|
16 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |
| D0251 |
|
16 |
12 |
$0.00 |