| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,269 |
1,813 |
$218K |
| D0120 |
Periodic oral evaluation - established patient |
2,833 |
2,805 |
$210K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,691 |
2,683 |
$178K |
| D1120 |
Prophylaxis - child |
3,827 |
3,795 |
$170K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,822 |
1,293 |
$153K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,445 |
3,923 |
$88K |
| D0210 |
Intraoral - complete series of radiographic images |
1,648 |
1,643 |
$79K |
| D0274 |
Bitewings - four radiographic images |
2,733 |
2,712 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,452 |
4,417 |
$58K |
| D1351 |
Sealant - per tooth |
1,721 |
506 |
$53K |
| D1110 |
Prophylaxis - adult |
559 |
559 |
$50K |
| D0350 |
|
3,806 |
1,746 |
$45K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
530 |
387 |
$42K |
| D4341 |
|
498 |
193 |
$34K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
63 |
54 |
$30K |
| D4910 |
|
328 |
325 |
$25K |
| D9430 |
|
779 |
744 |
$25K |
| D2954 |
|
83 |
57 |
$9K |
| D1310 |
|
134 |
134 |
$6K |
| D0272 |
Bitewings - two radiographic images |
458 |
455 |
$5K |
| D0330 |
Panoramic radiographic image |
160 |
160 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
392 |
379 |
$5K |
| D9993 |
|
81 |
81 |
$5K |
| D4342 |
|
106 |
38 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
12 |
$2K |
| D2330 |
|
22 |
16 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$1K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$1K |
| D0601 |
|
12 |
12 |
$180.00 |