| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
2,272 |
1,877 |
$73K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
910 |
500 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
768 |
764 |
$49K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
94 |
73 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
413 |
412 |
$31K |
| D0350 |
|
2,826 |
1,032 |
$27K |
| D1110 |
Prophylaxis - adult |
282 |
282 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
436 |
435 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,109 |
1,098 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,639 |
1,142 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
72 |
$8K |
| D1120 |
Prophylaxis - child |
155 |
154 |
$7K |
| D0330 |
Panoramic radiographic image |
227 |
227 |
$7K |
| D2394 |
|
59 |
39 |
$5K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$4K |
| D4341 |
|
54 |
28 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
316 |
312 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
13 |
$3K |
| D1320 |
|
187 |
187 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
30 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
175 |
167 |
$2K |