| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
6,528 |
2,420 |
$269K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,915 |
1,351 |
$190K |
| D1110 |
Prophylaxis - adult |
5,355 |
5,352 |
$185K |
| D2332 |
|
2,593 |
785 |
$158K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,779 |
1,082 |
$117K |
| D0330 |
Panoramic radiographic image |
4,077 |
4,073 |
$96K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
223 |
158 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,831 |
3,830 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
3,493 |
3,490 |
$67K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
860 |
643 |
$48K |
| D0274 |
Bitewings - four radiographic images |
2,094 |
2,092 |
$38K |
| D1120 |
Prophylaxis - child |
1,153 |
1,153 |
$35K |
| D2954 |
|
328 |
236 |
$31K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
108 |
104 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,576 |
2,570 |
$23K |
| D2791 |
|
77 |
55 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,407 |
2,403 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,437 |
1,437 |
$16K |
| D2330 |
|
396 |
191 |
$14K |
| D2331 |
|
144 |
62 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
973 |
971 |
$10K |
| D1351 |
Sealant - per tooth |
146 |
66 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
68 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$819.81 |
| D1330 |
|
19 |
19 |
$0.00 |